Resistance Training For Runners

Resistance Training For Runners

Guest Blog By Sam Hicks (Distance running coach and Personal trainer and owner 4 Runners)


Doing weights was once viewed as an activity carried out by gym junkies and Olympic weight lifters.

These days it’s become not only ‘in’ with the cool kids but highly recommended by medical professionals for the general population.

In distance running circles back in the good old days of marathoning it’s understandable to realise that lifting weights wasn’t highly popular among the elites.

And why would you as long distance runner, or any endurance athlete for that matter?

After all when it comes to specificity in training logic would say if you want to improve at running, just run more.


In addition doesn’t lifting weights give us bigger muscles which will end up becoming aerobically more expensive?  

But as training research advances and evolves more and more elite and recreational distance runners are including specific resistance programs into their training.

The main reason is injury prevention.

This means more consistent uninterrupted training that is likely to produce improved performance in race times.

We can break the benefits of resistance training down even further:

Improved musculo-skeletal health and strength

Strengthening of the running muscles and improved bone health.

Improved running economy

More strength can mean less ground contact time and enhanced “pop” from each foot strike.


Hormonal change (maximise anabolic response)

When the majority of your training time is spent completing extended periods aerobic exercise the body can enter catabolism “destructive metabolism”.

This can have detrimental effects on your overall health.

To reduce periods of extended catabolic states, an appropriate resistance training programme can be prescribed.

Combined with a healthy balanced diet will more than likely induce anabolism “constructive metabolism”.

So never fear stacking on excessive muscle mass from a couple of strength session per week.

Hypertrophy (enlarging of tissue) should only occur after specifically programmed sessions where this is the desired outcome.

But in the right dose, its likely strength gains will occur without excessive gains in lean mass.

Some examples of how strength training has helped runners…

Sir Mo Farahs (Multiple Olympic Gold medalist) ex coach Alberto Salazar running strength information:


Steve Moneghettis Biography Page 255 “In the long run” describes his weekly mileage daily breakdown plus his body weight strength circuit including push ups , sit ups , dips, chin ups ,leg raises etc.


If you’re unsure of how to structure resistance exercise into your program contact myself or another trusted  athletics Australia distance running coach , strength and conditioning coach or personal trainer that you trust to help with your running goals.

Sam Hicks is owner for 4 Running, an Adelaide based Running Coach and Personal Trainer.

4runners was founded by Sam Hicks in 2015.

As a level 2-advanced distance running coach and personal trainer, Sam himself is proof the systems that he use work.

“The methods I use are simple to understand, but not all are easy to execute”

Training for a distance running event can be overwhelming, leaving it hard to know where to begin.

4runners has been developed to remove the stress of knowing what to do in your program and when to do it.

Sam coaches long distance runners of all age groups, abilities using online correspondence to track your progress week by week. He tailors all the programs himself and monitors how the athlete responds to them.

Whether you’re a young novice 1500m track runner or a veteran marathoner, 4runners will cater for the individual.

“These systems are not new, flash or easy. They’ve been around since the 50’s. I’ve got so much confidence in them as I’ve experienced the results they produce.”

For more information, please contact Sam via this link.

Creating An Unbreakable Athlete - Part 1

This blog post was inspired by world leading sports scientist Tim Gabbett who recently posed the question,

Is it possible to develop an unbreakable athlete?

Tim elaborated on this on a recent podcast you can check out here.

My hope for this blog is that you may find something that resonates with you.

A (perhaps missing) piece that you can make part of your own unique and ever changing journey towards the holy grail of becoming an unbreakable athlete.

And if you think this article doesn't apply to you, in the words of Bill Bowerman,

"If you have a body you are an athlete".

The same principles apply for anyone who wants to break free of ongoing niggles and pain.

Be warned though, this blog is a long read, so get yourself a nice cuppa and get comfortable...

After studying the field of Physiotherapy for nearly 20 years now, I can say there’s no doubt that effective training is a blend of art and science.

There are a lot of opinions out there and it can be hard to figure out the right plan of attack.

In this blog I’ve tried to bring together the thoughts and opinions of world leading coaches, sport scientists and Physios and match it up with evidence based practice to help you achieve your goals.

We’ll try and put together a holistic and systematic approach that will develop a robust and resilient athlete, providing the foundation for planned training and competition.

I’ll also talk personally about some of the mistakes I’ve learned along the way.

Staying injury free

“The way to peak performance isn’t the secret, the secret is learning how to get to that point without getting injured along the way”

- Nick Willis dual Olympic medallist.

There is no one magical ‘correct’ way to train for everyone.

We all have our individual strengths, weaknesses, history and specific goals.

While we need to accept our approach will never be 100% perfect, we can always get better at it over the months and years.

Injuries are the number one factor limiting performance for athletes and the main obstacle holding you back from achieving your goals.

As well as reducing fitness dramatically, time off through injuries may also lead to weight gain and decreased physical capability, leading to a higher risk of future injury, sometimes leading to a downward spiral (See figure 1).

Ongoing injuries and time off training leads to an under-loading situation, and a perception of having a ‘vulnerable’ body that might break down at any stage.

Figure 1

Figure 1

Becoming An Unbreakable Athlete

On the other hand, if you can stay healthy for an extended period of time and put together some consistent weeks / months / years of training, improvement is virtually guaranteed.

Injury prevention needs to be a priority in your training plan with specific strategies in place (see below), otherwise you will break down sooner or later, especially as age catches up with you.

Really listening to your body and gaining self-knowledge about how you’re responding to your training and making appropriate adjustments to your schedule is what can make the difference between becoming an unbreakable athlete and ending up burnt out and not achieving your goals.

Addressing niggles / minor injuries early on and using a growth mindset can propel you towards becoming a resilient and robust athlete (see figure 2).

Figure 2

Figure 2

The ultimate cause of overuse injury

They say exercise is medicine and I agree with that.

But, you need to get the dose right. Too much or too little will lead to issues.

Research shows errors in load management are responsible for up to 75-80% of over-use injuries.

The perfect storm is when inadequate preparation (low physical capacity) meets with excessive training intensity and load (Figure 3).

Figure 3 Always keep this picture in mind !

Figure 3 Always keep this picture in mind !

Errors in load management can happen due to:

  • sudden excessive spikes in training load

  • over-training over time with insufficient recovery/adaptation

This is a recipe for disaster!

When your capacity is considerably lower than the demand placed upon it, your body remains in a constant state of stress and overload.

Injury is often a case of the straw that breaks the camels back, with signs and symptoms not heeded weeks or months beforehand.

There is a delicate balance between training and recovery and this can be difficult to achieve, especially if you are fueled by initial success and endorphin highs from challenging training sessions.

Unfortunately, in pursuit of gaining the competitive edge and high levels of internal motivation, injuries are very common.

Valuable time, energy and resources are then re-directed towards rehabilitating injured structures that can sometimes take weeks / months to heal properly.

As most older athletes can relate to, we can get stuck in a cycle of injury, pain and de-conditioning that can zap motivation quickly.

Sometimes it’s hard to see a way out when you’re stuck in the zone of stress.


For me as a runner, I’ve experienced just about every injury and made all the mistakes about increasing training loads too quickly.

So I can very well understand your frustrations about your body.

You can go from practitioner to practitioner looking for a magic cure.

But until we can zoom out and see the bigger picture of why we’re getting injured, (grasping the capacity vs demand concept), we may never truly get over our niggling injuries.

As a Physio, I enjoy helping people with diagnosing and treating injuries.

But my real passion is to empower people to build their physical capacity to a point where they can create a ‘buffer zone’ where they can achieve their goals without risk or worry of becoming injured.

To see someone get out of chronic rehab and get back to their best, and restore their confidence in their bodies is hugely satisfying.

That is one of the reasons I created the KIN Foundation training system that helps build the fundamental movement skills as a crucial stepping stone to more lofty physical goals.

Key Point

“It’s not the load that breaks an individual down. It’s the load they are not prepared for.” Tim Gabbett, PhD..png

A key point to be made here, is that it’s not the high demand and load that is generally the problem.

It’s how you go about preparing your body to handle that load.

Technically, you can build your capacity for any sort of demand, as long as you are well prepared for it.

An ultra marathoner who is well prepared for a 100km run may well have a lower risk of injury than a park runner doing their first 5km in 3 years.

I’m convinced it is possible to build an unbreakable athlete.

Let’s go into more detail…

5 Steps To Becoming An Unbreakable Athlete

1. Preparation

The first step in becoming an un-breakable athlete is to determine current physical capacity and know exactly where you’re heading.

If you’re a runner, you could do a 3km or 5km time trial that will determine your base aerobic capacity.

To assess your current musculo-skeletal capacity you could use the help of a Physio or Exercise Physiologist who would be able to guide through some testing.

With the help of a coach or physio, you can then use the feedback from your performance to structure a plan towards achieving your goal.

For example if you scored poorly on the aerobic test and felt out of breath really quickly - you’ll need to work on your cardio-respiratory fitness.

If you felt cramps or twinges in certain body parts - building specific structural capacity is what may be required.

Working closely with a Physio early on who can help you put together an indivdualised program can pay seriously big dividends later in your training program and avoid a lot of the issues of having things break down.

Preparing for the worst case scenario

A key part of becoming an unbreakable athlete is to identify the worst case demands on your body during competition.

For example, if you’re a runner with an upcoming race later in the year, you can break down the demands into more detail:

  • what is the exact distance?

  • what is the elevation profile - how many hills?

  • what sort of pace or time goal are you aiming for?

  • weather condition - hot, cold or windy?

  • what time of day will it start?

  • will it be crowded with people - are you used to running in big groups?

  • what time will the race start?

  • what is the transport like before the start?

  • what sort of nutrition and hydration is available on the course

To ensure your preparation is adequate, ‘begin with the end in mind’ and then start to train your body to be able to handle those specific loads.

Identifying the demands of running

To get more specific in terms of identifying the demands of running, I would say many people under-estimate the forces that are a placed on the body when you run.

Often there’s an assumption that running is a pretty natural form of exercise and that our bodies can easily handle it.

But when we look more closely, the figures can be a little disturbing.

The research shows, on average during the landing phase of the running cycle, we must absorb approximately three times body weight of force.

If we do a quick calculation - let’s say you weigh 70kg and go for a 10 km run (approximately 10,000 steps).

10,000 steps x 70kg x 3 times body weight = 2,100,000 kg of force

That is over 2 million kilograms of force your body needs to absorb, just for a 10km run.

You can see why many runners end up with a few niggles!

Running as a foundation for most sports

We know from the research that fatigue leads to higher injury rates and poor decision making capabilities.

We know of many world class golfers, tennis players and surfers who use running as their base foundation to improve their game and be able to compete with the best in the world.

If you play football, soccer or other sports - the demands will be specific to your position and your coach can give you more guidance as to training required.

In addition to running fitness, you may need to include strength, agility training and sport specific skills.

Keep in mind most AFL footballers and soccer players run around 10-15km in a game, so they need a huge aerobic foundation to be successful.

Most AFL clubs employ running coaches and exercise scientists to help prepare their athletes to compete at the highest level.

This blog post has a focus on running as it’s the foundation for most sports.

In fact running a half marathon (21km) can be one of the best barometers of your musculo-skeletal foundation.

2. Increase Capacity

The process of building your physical capacity to meet the demands of training and competition is known as load management.

On the face of it, preventing injuries should be pretty simple.

Just gradually increase capacity at a sensible rate until you meet (or even better exceed) the expected demands.

And sometimes this plan works smoothly, especially when you are young and robust.

Figure 4 below shows a fairly straightforward progression with the goal known as the ceiling and your current capacity as the floor.

Figure 4. Picture Credit: Tim Gabbett Training Injury Prevention Paradox Seminar

Figure 4. Picture Credit: Tim Gabbett Training Injury Prevention Paradox Seminar

Things get more complex when you are attempting to build capacity and have some risk factors, such as:

  • history of injuries

  • low tissue capacity

  • poor general base fitness

  • inadequate nutritional support

  • lifestyle factors such as sitting or standing all day at work

  • mental / emotional stress

  • poor sleep

  • poor digestion

  • over-weight

  • older age

Your physical capacity may well have bottomed out and we call this being in the basement (Figure 5).

Figure 5. Picture Credit: Tim Gabbett Training Injury Prevention Paradox Seminar

Figure 5. Picture Credit: Tim Gabbett Training Injury Prevention Paradox Seminar

You may be in the basement if you’ve:

  • had a long term injury and been unable to train

  • been inactive for many years and spent a lot of time sitting at work

  • recently been pregnant

  • had a flare-up of a chronic illness or recently had surgery

  • been on extended holiday

Getting from the basement to the ceiling is obviously going to be a longer, more difficult journey than if you started at the floor.

The other factor we have to consider is how much time you have to reach your goal.

The longer you have, the less likely you will be to spike your training loads and increase the risk of overload and causing injury.

Also it’s good to keep in mind that our body systems respond at different rates to training. For example cardio-respiratory fitness improves much faster than the muscuol-skeletal system (bones, muscles, tendons e.t.c) that may take months or years to fully develop.

Starting from the basement

If your current capacity is very low, it may be necessary to start with walking as your main form of aerobic exercise.

Walking is a seriously under-rated activity for athletes and especially runners.

If your goal is to eventually run a half marathon or marathon, walking has many benefits, particularly if you're coming back from an injury.

Here's 4 key benefits walking has for the runner:

✔️ Increases blood flow to aid recovery

✔️ Encourages gradual loading of tissues and creates a bridge to safely achieve higher loads of running

✔️ Helps maintain a healthy body weight

✔️ Mental benefits of staying active and achieving small wins & avoiding complete rest (that can dramatically drop your physical capacity)

If you can build your walking capacity to 30-40km per week, you will have an excellent foundation for layering in some running safely down the track.

Getting the foundation right

As you’re building capacity, there are three main variables in your training:

  • volume

  • frequency

  • intensity

If you imagine a sound mixing board with all the various levels you can adjust.

Obviously it would be unwise to increase all the channels at the same time.

For runners it’s fairly well accepted that your first priority is building your low-intensity volume and then layering in your speed and race specific training towards the end of your training cycle.

Some recent research from the Journal of Strength and Conditioning Research has suggested that world-class long-distance running performances are best predicted by volume of easy runs (and deliberate practice of short-interval and tempo runs).

This novel study shows that there is a crucial role for long, easy runs that contribute to greater volumes of running, allowing for improved cardio-vascular efficiency (building a better engine) and optimal physiological functioning.

Arthur Lydiard the legendary New Zealand running coach strongly advised building this low-intensity aerobic base over a period of at least 3 months, (or 4-5 months if you’re starting out) and then building your race specific work later (see Figure 6).

Figure 6

Figure 6

Without the aerobic base, the more intense anaerobic training falls over and results become unpredictable.

The dramatic increase of injuries seen in team sports such as the AFL I believe can be traced back to players not getting significant component of endurance-based work in the pre-season.

Their bodies are put under enormous pressure with sprinting and high intensity drills placing extreme demands on them right from the early stages of their preparation.

Building Your Optimal Running Volume

Figure 6 below gives you some guidance on your ideal weekly mileage to aim for (in kilometers), depending on your experience level and your running goals.

Figure 6.

Figure 6.

Building higher volume initially will mean you’ll need to keep your intensity on the lower side.

To figure out what pace you should be doing your easy runs, there are a few online calculators that can help you.

The one I really like is Luke Humprheys Running Caclulator that you can find here:

Running Calculator

You can enter your most recent 5km time and see the pace range you should be aiming at for your easy runs.

It also gives you an accurate idea of your training zones for specific goals which is super handy.

Knowing and respecting your individual ‘easy’ zone pace (zone 1 and 2) is probably the single most important factor for a beginner runner to learn (see Figure 7).

Matt Fitzgerald has done a great job of explaining the finer points of getting your training intensity ratio right with his book 80:20 Running: Run Stronger and Race Faster By Training Slower.

Figure 7

Figure 7

Volume First, Speed Second

Here’s where Tim Gabbett’s training paradox comes into place.

Traditional thinking would suggest the more volume and training you do, the higher the ‘wear and tear’ on your body and the greater risk of injury.

This school of thought believes that training is important, but you’ve got to limit yourself, so you will be OK for competition.

However, the research is pretty clear that wrapping yourself in cotton wool from a training perspective leaves you unprepared to meet the demands of your sport, and opens your risk to developing an injury.

So hard and appropriate training is important - but you obviously can’t go out and give 110% in every training session.

Capacity must be built slowly by gradually expose yourself to higher demands.

Benefits of building low-intensity running volume base first

  • increase capillary density and mitochondria in muscles

  • improved running technique and efficiency - every stride is practice and improving your neuro-muscular efficiency

  • improves muscle strength and endurance

  • increases blood flow and circulation, leading to healthier tissues and aiding recovery

  • improves mind - body connection (can become aware of weak links early in the training cycle and strengthen them with a specific plan)

  • improves aerobic capacity, setting the foundation for the rest of the training to build upon

  • helps burn fat and maintain appropriate weight

Picture Credit: Hansons Marathon Method Book

Picture Credit: Hansons Marathon Method Book

Tips for building base mileage

  • think about getting more time on feet than achieving a certain pace

  • pace should be relaxed and easy - it should pass the ‘talk test’

  • keep your cadence relatively high, while maintaining a gentle pace (takes some practice)

  • insert walking breaks whenever you feel like you need it

  • keep your feet fresh by rotating between 2-3 of running shoes

  • get onto the trails where you can take some pressure off your joints and enjoy being out in nature

  • listen to running podcasts…highly recommend the Inside Running Podcast

Discovering your weak links

Most of us have some weak links in our body that we may never know until we start to increase demand.

As you’re progressing in training, the harder sessions will ‘test’ your physical capacity and movement foundation.

The benefit of building your low-intensity volume in the initial few months of training is that it can expose weak links in your body, without risking huge strain on your body.

Because there is no pressure to be fast and progress too quickly, in this phase you can take your time to properly address the issue.

Figure 8

Figure 8

The bigger the upcoming performance, the deeper your foundation has to run to support the demands (See below Figure 8).

Identifying your weak links can sometimes be really easy - it’s the area of your body that is overloaded and painful.

But there is often also a deeper root cause of why a certain tissue is getting overloaded.

That is where a good Physio can help you do some detective work and identify the more subtle biomechanical issues that may be contributing.

These issues may be things like:

  • weak or inefficient core muscles

  • inactive glutes

  • stiff ankles from past injury

  • tight hip flexors

  • poor body awareness

Won’t all this easy running make me slow?

Screen Shot 2019-02-20 at 4.36.34 pm.png

For many years I followed more of a high threshold training approach, believing that training at the pace you want to race at would stimulate the most beneficial training gains.

As a younger athlete with good recovery powers, this seemed to work well.

I did throw in some occasional slower runs, but to be honest I felt guilty doing them because it felt like going slow was completely counter-productive and my body would become soft.

As I have gotten older though, things changed. Harder training sessions took more of a toll and recovery was not as good as it was when I was young.

The old ego was not allowing me to get the proper training that I needed.

It wasn’t until I had a good discussion with running coach / podiatrist Michael Nitschke and he showed me this graph of the training intensity ratios of elite runners.


This was a really good wake up call.

The 80/20 principle of training came into full realization.

Once I fully accepted this principle, a weight was really lifted off my shoulders.

Suddenly I had the green light to run easy, and not feel guilty!

I distinctly remember my first conscious effort to run along at an easy pace.

It was really hard to slow down and be disciplined.

But after about 10 minutes I got over that and then started thinking - this so much fun!

Running suddenly turned into a pleasurable activity, when I wasn’t picking up the pace and burning out with fatigue on every run.

Admittedly the results of this approach to took a little longer to appear.

The ego and running pace takes a short-term hit.

But 6-12 months later, a solid foundation had built up from which faster running will come.

Invest in your training and reap the dividends

To use an analogy, running is like how you manage your money.

Easy running / building up high volume is like building your savings.

Every time you can go out for a jog without pushing into your red zone / high intensity, you’re building up your account.

Every minute your working hard above your threshold you’re spending money.

If you spend more than you save, you’ll go into debt pretty quickly and the bank will call you up and demand you start paying back what you owe.

Injuries are like going into debt.

If you can be disciplined and sensible, investing your savings over time (building your low-intensity volume) over many months and years, you’ll get to really enjoying spending the dividends on race day.

“The less effort, the faster and more powerful you will be” - Lao-tze

Efficient vs Effective Training - The tortoise and the hare

In terms of producing short-term results, there’s no doubt doing threshold runs and pushing your intensity gets you fit and ensures rapid progression towards your goal.

In terms of time invested vs results, this is a highly efficient way to train.

But because each week is full of hard training, it means there is a limit to how much capacity you can generate as you need to allow for rest and recovery.

Your improvement will be quick in the beginning but will begin to plateau fairly quickly.

As your fitness reaches as a plateau, improvements can be smaller, and because of this the temptation is to push even harder in training, naturally leading to an increased injury risk.

On the other hand, effective training, as proposed by Lydiard, recommends more of a pyramid training approach, with the emphasis on increasing total capacity (achieving higher volume mileage) in the beginning of a training cycle.

By starting off slowly and gradually building up can possibly yield better results in the long-term.

The story of the tortoise and could be analagous to the training styles.


As stated above, there is no one ‘right’ way to train for everyone and the research is still lacking.

The important thing is to listen to your body and if somethings working well that stick with it.

But if you’re having ongoing niggles or have plataued in your training, you may need to re-assess your training approach.

Part 2 To Be Continued…

Pain on Inside of Knee? Get To Know Your VMO

If you’ve ever had a nagging pain on the inside of your knee or a knee that seems to buckle or give way, there is a fair chance you’ve had some dysfunction in the VMO muscle.

VMO dysfunction is very common in runners, hikers, cyclists, athletes involved in jumping sports and after any knee injury.

In this short blog, we’ll find out more about how issues develop in the VMO and what you can do to help.


VMO stands for Vastus Medialis Oblique and this is part of the quads, running along the inside of the thigh, with the bulk of the muscle sitting directly above the inside of the knee.



The role of the VMO is to assist with extending your knee and arguably the most responsible muscle for knee stability, as it helps control the alignment of the knee-cap.

When the VMO isn’t functionally optimally, the knee cap tends to shift slightly out of place during movements such as squats and lunges, causing pain and inflammation behind the knee-cap.


When the quads get overloaded (suddenly or over time), tightness in the muscle fibres (called trigger points) can refer a toothache-like pain deep in the knee joint (see Figure 1 below).

This pain from the overloaded VMO muscle can often be confused with joint pain such osteo-arthritis or a meniscus tear, as the location and type of pain are often similar.

Figure 1

Figure 1

The initial knee pain then may disappear after a few weeks, only to be replaced by a sudden weakness in the knee (a condition called “buckling knee”) that causes a person to unexpectedly fall while walking.


The VMO can be activated as a protective response to knee injury such as to the ligaments, meniscus or post-surgery.

The VMO is also commonly overloaded with repeated use in the following situations:

  • suddenly increasing your volume of running or cycling (running places around 6 x body weight through the quads)

  • a new (or sudden increase) in an exercise program involving repetitive squats, lunges, leg extensions or wall sits

  • jumping sports e.g. basketball

  • cycling - poor bike fit

  • walking downhill or stairs

  • being over-zealous in rehabbing the VMO - too much strengthening too soon


Physiotherapy assessment will involve a comprehensive movement assessment to determine the cause of your VMO issue.

“Short term treatment such as soft tissue massage and dry needling is very helpful, while long term building capacity in the quads, glutes and core is critical to prevent a relapse.



Tightness and contraction of the VMO responds very well to dry needling, which can de-activate the trigger points (knots in the muscle).

The benefit of dry needling is that it can reach the deep fibers of the muscle and lead to a quicker resolution of symptoms. 

Treatment of the VMO is generally very responsive to treatment, provided the contributing factors are addressed.


  • apply heat to the VMO muscle 10 minutes each day to increase blood flow and reduce tension

  • if you’re a runner or hiker, avoid the hills (in the short-term)

  • ensure your shoes are not overly worn

  • when running - avoid over-striding, ensure proper warm up and cool down and take walking breaks frequently to avoid overloading the VMO

  • avoid prolonged kneeling on the floor e.g. gardening, washing floors - use a low bench or stool to sit on instead

  • foam roll the VMO daily for a few minutes (see below). It’s also a good idea to roll out the adductors which are also commonly tight

Foam Roller for the VMO:

Foam rolling the inner quad and adductor - fun times!

Foam rolling the inner quad and adductor - fun times!

Questions or concerns about your knee pain?

If you are curious about how we can help with our knee pain, I’d love to help you out.

Please leave a comment below or send an email direct to

If you’d like to get your knee on the fast track straight away, please use the button below to schedule an appointment online:

Building A Resilient Knee For Running

Building A Resilient Knee For Running

Important Note: This blog post is very general in nature. Some or all of the advice may not be appropriate for you. Please check with your Physiotherapist for specific advice on your condition.

If you’re fairly new to running - and tell your friends and family you’re planning or running a marathon or half-marathon, very often you get this well intentioned question:

Screen Shot 2019-05-14 at 1.16.57 pm.png

While we can easily shake off the comment at the time, it’s often not until a few months down the track, when your training volume starts to increase, you may in fact start getting some twinges in the knee, that the comment can come back to haunt you.

An element of doubt can sit in the back of your mind, making you question:

“Is running actually harming my knees”?

“Were they right after all”?

So what does the research say?

There’s a common view in the community that running isn’t good for your knees, and may cause early wear and tear and possibly lead to arthritis.

So what does the research actually show?

A very high quality study recently came out that followed over 100,000 people to see how their lifestyle and exercise habits related to their risk of developing knee arthritis.

The study showed that recreational runners had a risk of developing knee arthritis that was around 3.5%, compared with non-runners whose risk was 10.2%.

Knee arthritis risk: Runners vs Non-Runners

Knee arthritis risk: Runners vs Non-Runners

In other words the non-runners had a three times greater chance of developing knee arthritis that runners.


Rather then their joints ‘wearing out’, runners had increased muscle bulk around the knee, providing a protective effect on the joint.

This study allows you to be confident that recreational running will not harm, and may actually improve, your hip or knee joint health.

Biggest Risk Factor

So if running doesn’t cause arthritis in the knee, then what is the biggest risk factor?

If we look at the research again - the biggest risk factor for knee arthritis was being over weight.

So in terms of knee arthritis, the risk of being inactive and becoming overweight is much greater than being active and running regularly.

Knee pain and running

So… we know running doesn’t cause arthritis - (it actually might prevent it).

However, the knee is still a very common area of pain and injury for runners (in fact 50% of all running injuries are in the knee).

Photo Credit: Rich Wily Running Symposium La Trobe 2018

Photo Credit: Rich Wily Running Symposium La Trobe 2018

Patello-femoral Syndrome

The most common running related injury is what we call Patello-femoral Syndrome (also known as Runner’s Knee).

Patellofemoral pain (PFP) is a condition where pain is felt on the front of the knee, either around or behind the patella.

It is caused by an increased load and force going through the knee-cap that, resulting in inflammation and swelling around the knee.


The main symptom of Patello-Femoral Syndrome is pain with loading and a general vague ache in the front of the knee.

The pain generally gets worse with:

  • running especially downhill

  • climbing stairs

  • kneeling and deep squatting

  • sitting with knee bent up for prolonged periods e.g. sitting on a plane or movie theatre

Key Point:

A key point here is that knee pain from running is most likely related to inflammation around the knee cap rather than any structural joint damage.

The confusing thing is that the aching pain from patello-femoral syndrome can mimic the pain you may feel in the early stages of knee arthritis.

No doubt this can be a little disconcerting.

But you definitely don’t need to freak out about developing knee arthritis.

2 choices:

When you develop knee pain as a runner - you have 2 options:

  1. Keep running and push through the pain barrier.

    Sometimes this can help and the pain goes away. But sometimes the pain doesn’t get better and things just get worse. Runners traditionally have very good pain thresholds - but the jury is still out if this is a good thing or not!

  2. Stop running altogether.

    As runners, we know when you stop running, you tend to lose your fitness really quickly. Your capacity decreases rapidly and your muscles become de-conditioned and so just resting doesn’t really solve anything. When you get back to running, the pain and inflammation is just as bad as before.

Thankfully there is a 3rd option - and the rest of this post will be talking about five very practical strategies you can use to help reduce your knee pain and get back to running.

5 Strategies to help with knee pain and get you back to running

Before we start, we need to get on the same page.

Unfortunately there are no quick fixes.

There are multiple factors (20-30!) that may all play a role in why you’ve developed knee pain.

Without doubt, the best results come with a personalised assessment with a Physio who has a special interest in running.

This will help identify the main issues and get you on the fast track to healing.

On average, it takes 8 - 12 weeks to reduce knee pain and get back to running properly again.

Getting healthy again will test your patience, and it is very often a case of 2 steps forward 1 step back.

1. Reduce Inflammation


If we go back to the original cause of the patello-femoral pain in the knee - it is inflammation that develops under the knee cap.

If you have knee pain, it means you have inflammation.

So the first and most important step is to reduce the inflammation in the knee.

The best way to do this is to use a good quality ice pack on your knee for 15 mins x 2 day (every day for 2 weeks).


The ice packs we sell in the clinic are the Sideline Ice and Wrap ($39)…they are a great option.

Using the velcro strap means you can get a solid compressive effect and still keep moving about, without having to stay seated the whole time.

Often the knee starts to feel better quite quickly when you decrease the inflammation, but it’s important to keep icing for 2 weeks so you completely break the inflammatory cycle.

If you start to feel better and then return to exercise too quickly, you will start the inflammatory process over again.

Another good option when you have knee pain is getting into a pool or standing in the cold water down at the beach. The buoyancy of the water can have a positive impact on decompressing the knee.

We don’t tend to use anti-inflammatory medication, unless the pain and inflammation is severe.

2. Reduce Load

Generally, activities with more knee bending increases stress to the Patella-femoral joint.

So to reduce irritating your knee further, you will need to:

  • reduce heavy weights especially lunges and squats

  • avoid stairs

  • avoid kneeling

  • avoid sitting with your knee bent up for prolonged periods

Sometimes you also need to avoid a quad stretch as this can also irritate the knee joint

Reducing Load When Running

If at all possible, we like to keep you running in the short-term, with a few alterations.

Some common modifications include:

  • avoid downhill running and keeping to flat ground as much as possible

  • reduce speed and include some more walking breaks (especially when you feel knee pain)

  • do shorter, more frequent runs rather than longer runs

If running is still too sore you may need to take a complete break for 1-2 weeks.

In this time, you can generally keep walking and getting in the pool can be helpful too.

Some people like to get on the bike, which can be a good option to maintain your cardio-vascular fitness. However you need to be wary of developing muscles imbalances that cycling can often accelerate - most commonly increased hip flexor tightness and under-active gluteals.

3. Increase Tissue Capacity

If we look at which muscles are loaded when we run, the soleus muscle in your calf (takes up to x 8 body weight) and the quads (up to x 6 body weight).

Photo Credit: Rich Wily Running Symposium La Trobe 2018

Photo Credit: Rich Wily Running Symposium La Trobe 2018

They already work a lot so it probably doesn’t make a lot of sense to increase the strength of them, especially if you are running a lot and doing hills regularly.

But the accessory muscles such as the hamstrings, gastrocnemius, and the glutes have all got potential to improve their capacity and help off-load the knee.

Some common exercises you could include would be calf raises, bridges, clams, crab walks and hamstring curls on the ball.

Getting a Physio to develop a personalised program for you will provide many benefits in the long term and keep your knees from getting overloaded and inflamed.

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4. Create Neuro-muscular balance

Many people think of the knee as a simple hinge joint.

While the joint does act like a hinge, there are around 20+ muscles that attach and need to be balanced around the knee.

If you are a musician - anyone who plays the guitar - you know that every time you play, you spend a couple of minutes ‘tuning’ up, before you play.

If your strings aren’t fine tuned properly then obviously your going to sound terrible!

The muscles are like the strings of the guitar, and tend to get overloaded and tight with running, leading to increased loads on the knee-cap.


Keeping your muscles in tune could include things like:

  • foam rolling

  • stretching

  • deep tissue massage

If your muscles are having a bit of trouble releasing, then the next step would be to try dry needling.

Trigger point dry needling has the ability to reach deeper into the muscle, getting a more effective release.

You can find out more about dry needling here.

5. Modify Running Gait

There is some solid evidence showing that making some small modifications to your running gait can take pressure off your knee.

Returning to running after a knee injury can be a little scary.

We find sometimes people can be a bit over-cautious and defensive and this leads to a very upright posture, almost running within yourself.

Counter-intuitively, this upright posture tends to increase the force on the knee…so switching to a forwards lean is a simple solution.

Some studies have shown that incorporating a forwards lean can improve your running efficiency by up to 30%, as you tap into the power of gravity.

It’s important to lean forwards from your ankle, rather than bending from your waist, that could lead to pressure on your lower back.



A common thing with knee pain in running is over-striding.

This can lead to increase peak forces going through the knee.

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The solution is to modify your cadence (how many steps you take per minute).

Generally, increasing your cadence 5-10% can significantly decrease the peak load of force going through your leg.

For example, if you’re at 165 steps per minute - increasing to 175 - 180 may do the trick.

Many GPS watches track your cadence in real-time, or you could use a metronome app on your phone to help keep your rhythm.

Side note: Running with a faster cadence doesn’t mean you have to run at a faster speed. There is an art to learning to shorten your stride, but still run at a comfortable pace - it can take some practice.

Return to Running

Just a few final tips about returning to running from a knee injury:

  • for the first 3-4 weeks, choose a flat surface to run on and gradually layer in the hills as your pain allows

  • before you run - do a quick tune-up - foam rolling, gluteal engagement exercises

  • try taping the knee. About 50% of the time, using a rigid tape can make a huge difference in stabilising the knee cap. The other half of the time it doesn’t make much difference, so it is worth trying out - and your Physio can show you how

  • shoes - a new pair never goes astray after an injury and will help take the full shock absorption with less pressure on the knee

Pain as you return to running

As you return to running, your knee may still be twingy.

The following scale is useful to keep in mind and rates your pain level from 0 (no pain) and 10 (worst pain you could imagine).

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Of course, ideally the pain would be 0, and that’s great if that’s the case.

In reality, you may still have some twinges and soreness as you’re getting back into it.

This is really common and is often more related to the knee getting used to the loads again, rather than more damage.

We rate a 0-5 pain score as an acceptable level.

You can still run, but just be mindful, if your pain increases to a 6 or greater, then you need to stop and walk / rest.

Take note of your pain levels at the time of exercise, and also the 24 hour response.

Pain that lasts until the next day means you’ve probably done too much, so next time reduce the amount so your body can handle it and gradually build up from there.

What about if you already injured your knee - is running still OK?

That is a great question, and it is very hard to say without a personalised assessment.

If you have previously torn a ligament or meniscus in your knee - some doctors would suggest you avoid running forever.

However, if we go back our research showing the biggest risk factor of knee arthritis is being over-weight, there is a case to be said for gradually re-introducing running (if it’s something you enjoy), as a means of maintaining effective weight control and creating a supportive muscular foundation for the joint.

Following the five strategies outlined above would most likely be a great help, but again please consult with a Physio to get a tailored plan set up for you.

Avoiding surgery

Some recent research has demonstrated that 65 per cent of people with knee arthritis and meniscus tears can avoid surgery by following a physiotherapy program (Katz et al. 2013).

The protocol involved an individualized physiotherapy treatment plan with a progressive home exercise program

The three-stage structured program was designed to:

  • decrease inflammation

  • improve range of motion

  • optimise muscle strength

  • improve aerobic conditioning (e.g., with the use of a bicycle, elliptical machine, or treadmill)

  • proprioception and balance re-training


Running is safe - it definitely doesn’t cause arthritis and may even protect your knees.

Knee pain is common however and the most common cause is knee cap pain.

Listen to your body - respect it - get in touch with Physio who can guide you back to running safely.

Rather than pushing through the pain or stopping alltogether, try the 5 Strategies:

  • decrease inflammation using an ice pack

  • temporarily decrease load

  • increase tissue capacity with some simple strengthening exercises

  • create muscle balance

  • modify your running gait

If you have any other questions about knee pain and running, I’d love to help you out.

You can send me email to

If you’d like to get started on your journey back to running pain-free again, simply click on the link below to schedule an appointment.

The Obstacle Is The Way

This blog post was inspired by Ryan Holiday’s book, The Obstacle Is The Way, which describes how employing the philosophy of Stoicism can turn our ‘trials into triumphs’.

This book got me thinking about how we approach issues such as sporting injuries, chronic pain and loss of function that we see in the clinic.

Obstacles such as chronic pain are becoming more prevalent in Australia, with one in five adults reporting they suffer with moderate to severe pain everyday.

It is clear, as a rehab community, we are collectively not doing a great job at helping.

The longer I work as a physio, the more I see how the right mindset and beliefs are a key factor in recovery.

Reading more about the Stoic philosophy, I could see how my values as a health care practitioner aligned closely with with this approach.

The average person has about 50,000 thoughts per day, and for someone who is in chronic pain, you could imagine a large percentage of those thoughts could be centered around these three questions:

  • what is going on?

  • how is this going to get better?

  • when is this going to get better?

When they experience injuries, it’s common for athlete’s (even weekend warriors) to feel anxious and depressed.

One study of 343 male college athletes found that 51 percent had some symptoms of depression after being injured.

Addressing beliefs and attitudes early on can provide the foundation to a successful return to full function.

Downward Spiral Of Injury

We know that a previous injury is the biggest risk factor for another injury.

And that means as a rehab community, we have some work to go in terms of educating and providing injured people a comprehensive rehabilitation program in order to prevent compensations and further issues.

Without inadequate rehab, a downward spiral of pain and injury can develop, eventually leading to burnout.

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Stoicism - a little background

Getting back on topic!

Stoic philosophy was founded in Athens in the early 3rd century BC, and was practiced by the likes of Epictetus, Seneca and Marcus Aurelius.

Ryan Holiday writes specifically of being inspired by Marcus Aurelius, whose quote inspired the book:

“The impediment to action advances action.

What stands in the way becomes the way.”

Marcus Aurelius, as well as being one of the most successful Roman Emperors, had his own private struggles with chronic pain in the chest and stomach.


His personal notes practicing Stoic philosophy, The Meditations, refers many times to psychological strategies for coping with pain and illness.

His physical resilience and endurance was remarkable, despite not having ideal physical health he was to become one of the most respected emperors in Roman history.

Mindset Shift

One of the biggest lessons taught by the Stoics was to re-conceptualise your obstacles from something to avoid to something to welcome, as a means of growing stronger and more resilient.

Obstacles give you important clues as to where you may have some ‘weak links’ and provides an opportunity to turn them into strengths.

Following a Stoic philosophy involves re-wiring your thinking, shifting from negative emotions such as from worry, anger and frustration to calmness, gratitude and hope.

To be clear, negative emotions can be healthy and natural.

But at some point, they become more of a hindrance to your forward progress.

With the right plan in place, and plenty of patience, grit and perseverance according to leading sports scientist Tim Gabbett, you can turn yourself into an unbreakable athlete. 

“It is a rough road that leads to the heights of greatness” - Seneca

“It is a rough road that leads to the heights of greatness” - Seneca

Short Term Pain Coping Strategies

Of course if your only goal is to avoid pain, there are some strategies that can bring about some fast relief.

Using pain-relieving medication has it’s time and place.

But unfortunately we’ve seen the long term consequences of opioid medications (e.g. tramadol, oxycontin and codeine) that can sometimes lead to addiction and other serious side effects.

And we now know from the research that these drugs create a long-term increased pain sensitivity, making your pain levels greater than before you started taking them.

The other problem is once you come off the medications, you haven’t any had an opportunity to learn from your pain and injuries, so you essentially need to start all over again.

Instead of relying on pain medications, here’s eight practical strategies, inspired by the Stoic Philosophers, over 2000 years ago, to help you overcome your pain and live the best life you possibly can:

  1. Accept Pain And Injuries 100%

The Stoic philosophers were big on understanding the rhythms of nature.

Just like stormy weather, it would unwise and naive to believe you would never have a pain or flare-up in your body.

No one gets out of life without serious challenges along the way and no one is immune to experiencing pain.

However, the difference lies in how we perceive and respond to it.

A real life example world would be to consider how a sailing boat gets from point A to point B if there is a direct headwind blowing in their direction?

Would the sailor just give up and think it’s not worth the hassle?


The experienced sailor would no doubt accept that unfavourable winds are going to happen some of the time - that is a normal part of life, and they wouldn’t get overly emotional when it occurs.

For the sailor who is committed to reaching point B, the solution, is to change tack.

If the boat turns onto a 45 degree angle, then the sails are able to pick up the wind and use it to the boats advantage.


Progress is no doubt slow and frustrating, but it is still forward momentum and getting you closer towards your goal.

When the winds eventually turn favourably, you would have built up a decent reserve of resilience and capacity.

Bottom line: there is a season for pain and it is a normal and inevitable part of life.

Keep breathing, batten down the hatches if necessary.

The storm will pass.

2. Let Go Of Your Fight Against Pain

Following on from the first point, counter-intuitively, to overcome your pain, you must be at peace with your pain and fully accept it.

The struggle, the fight and the mental battle against your pain only ends up wasting precious energy and resources, that could otherwise be better spent.

Being trapped in a state of resistance and anxiety leads to your body into a fight or flight mode where your muscles are held in a constant state of tension.

This can lead to even more problems than your initial injury.

Common muscles that are involved in the fight / flight response are:

  • neck / trapezius

  • hip flexors

  • lower back

  • TMJ jaw

  • shoulders

Once you can find acceptance, a significant burden is literally lifted from your shoulders.

With the guidance of a health care professional, it’s important to let go of your anxiety and find a place inside that is relaxed.

“Sometimes, your only way out of the pain is through the pain”

3. Imagine The Worst Case Scenario

The Stoics proposed, rather than avoiding the pain, we must accept it and then confront it.

Once you are feeling more relaxed and in control of your emotions, Stoicism actually encourages you to imagine the worst case scenario in terms of your pain experience.

If you could courageously come to terms with the worst case scenario - and see how, while it would be difficult, you would definitely still be able to cope.

Practicing this exercise mindfully can help reduce the fear around pain, injury and loss of function, knowing that you will be able to manage, no matter how bad things get.

4. Good vs Bad?

Injuries can often be thought of as ‘bad’.

But are they really?

This reminds me a of a story about a farmer.

One day his horse runs away. And his neighbor comes over and says, to commiserate, “I’m so sorry about your horse.” And the farmer says “Who Knows What’s Good or Bad?”. The neighbor is confused because this is clearly terrible. The horse is the most valuable thing he owns.

But the horse comes back the next day and he brings with him 12 feral horses. The neighbor comes back over to celebrate, “Congratulations on your great fortune!” And the farmer replies again: “Who Knows What’s Good or Bad?”

And the next day the farmer’s son is taming one of the wild horses and he’s thrown and breaks his leg. The neighbor comes back over, “I’m so sorry about your son.” The farmer repeats: “Who Knows What’s Good or Bad?”

Sure enough, the next day the army comes through their village and is conscripting able-bodied young men to go and fight in war, but the son is spared because of his broken leg.

And this story can go on and on like that. Good. Bad. Who knows?

Be at peace with your path and have faith that everything happens for a reason.

There is no good or bad to the practicing Stoic, there is only perception.

5. Switch From Goal Oriented To Process Oriented

While you can learn the principles of Stoicism, the philosophy is actually one of action.

A Stoic needs to focus his attention on action in the present moment of time because neither the past nor the future can be changed.


Being process orientated, you start to focus on all of the small daily things you need to do that all add up to produce the end result.

Come back to the present moment.

That is where the power is to change your life for the better.

Take the focus off being pain-free and instead put your focus on the process.

What are the small daily tasks you need to do to become pain free?

“Luck is what happens when preparation meets opportunity.” ― Seneca

6. Understand Your Pain

“We are more often frightened than hurt; and we suffer more in imagination than in reality.” Seneca

There is no doubt that ongoing pain that is unexplained can be frightening.

With the help of your Physio and Doctor, if you can understand that some degree of pain is a normal part of the healing process, you can relax in that knowledge.

It’s important to realise that whatever pain you experience should be related to a certain physiological process.

For example:

Ankle sprain —> inflammation around the ligament, you can expect some soreness for 4-6 weeks

Lower Back pain —> occasional flare-ups, especially if sitting too long. Disc injury takes around 3 months to heal

Tendon degeneration —> worst in the morning and with sudden changes in training volume, hills or speed work

Knee - patello-femoral syndrome —> (pain in front of the knee cap) take on average 3 months to get better and pain relates to irritation behind the knee cap and gets worse with squats, kneeling and stairs

Nerve related irritation or damage —> could be many months or years of altered sensation in the affected area

Muscle pain —> the most common source of musculo-skeletal pain - lack of oxygen to the muscle from poor posture, excess muscle tightness or injury.

Chronic pain (more than 6 months) —> relates to increased sensitivity in the nervous system which magnifies minor tissue problems. It may come down to the fact, that we all have wear and tear and issues in our body, for whatever reason, the body and nervous system has decided to heavily focus on that particular area.

If there is ongoing pain and you are not sure why, then you may need to talk to your health care provider in more detail.

7. Develop A Growth Mindset

Stoic philosophy has a lot in common with the Growth Mindset approach, developed by Carol Dweck.


According to this approach, the most important word in the dictionary is ‘yet’.

Re-frame your challenges…

“I haven’t completed the marathon…yet”

“I haven’t felt strong and pain-free in my lower back…yet”

“I’m not sure what it feels like to walk without pain…yet”

8. Train Your Mind To Endure Pain And Discomfort

It takes practice to exhibit self-control with our perceptions of life’s obstacles.

You can practice - the next time your stub your toe or get a paper cut.

Pause for a moment and see if you can absorb the sensation of discomfort - without reacting to it.

One of the great things about exercise is that it is a form of discipline where you willingly put yourself in a position of discomfort for a period of time, with the hope that you will come out the other side better off physically or more importantly mentally afterwards.

As you practice pushing yourself to the threshold, you will build a reserve of willpower to draw from as necessary, creating a “Inner Citadel” of strength and resilience.

For me personally, that is one of the reasons I enjoy the process of running so much.

Every time I go for a run, I know I will confront the pain of a body wanting to stop.

To achieve any sort of reasonable time, you need to learn to listen to your bodies pain, but constantly re-directing your attention and keep pushing to achieve your goal.

“Faced with pain, you will discover the power of endurance” - Epictetus


Pain and injuries are never easy.

But with the right attitude, they can be an valuable internal guide to making you better and stronger than before.

What seem like insurmountable obstacles become once in a lifetime opportunities.

If you’d like to find out more about Stoic philosophy, I’d highly recommend you check out the book, The Obstacle Is The Way.

Now it’s over to you,

What’s the biggest obstacle you’ve faced? What benefits were you able to derive from it?

I’d love to hear your thoughts in the comments section below.