Running a Safe Running Program

by Dr. Joseph Guettler

During the spring and summer months here in Michigan, the outdoor recreational running season definitely shifts into high gear.  Everywhere you look – on the streets and sidewalks, in the parks, and on the tracks – people are running. 

Now, running is undoubtedly a great exercise, but it is also an impact activity – and there are a myriad of overuse injuries that can afflict runners.  Although I see plenty of runners who present with shin splints, stress fractures, plantar fasciitis, and tendonitis of the hip, thigh, and ankle, we’re going to focus on the most common “running problem” that I see in my practice: “Runner’s Knee.”  It’s a name that describes those aches, pains, and problems that occur around and behind the knee caps of runners and other athletes.  The more appropriate name is actually patellofemoral syndrome.  This term encompasses several different clinical entities that can occur:

  • Tendonitis of the patellar or quadriceps tendon
  • Chondromalacia Patella which is the term used to describe softening and fraying of the cartilage behind the knee cap
  • Patellar Maltracking that results in chronic pain and/or actual dislocation of the knee cap.
  • Apophysitiswhich is the term used to describe irritation of the small growth plates in the front of the knee.  It occurs in children and adolescents.  One of its other names is Osgood Schlatters Disease.


Symptoms generally include an aching pain under or around the kneecap (patella).  The pain can occur during or following activity.  Pain can sometimes be sharp, and in cases of patellar instability, the knee cap may actually slide out of the groove.  Popping, catching, and swelling may also be present.  Pain generally occurs with activities that include running and jumping, but it is also common when walking up or down stairs, kneeling, squatting, or sitting with a bent knee for a long period of time (called the movie theater sign).


Runners, jumpers, and other athletes such as tennis, basketball, and volleyball players put heavy stress on their knees.  I tell my patients that the front of the knee is a “lightning rod” for problems because of the tremendous biomechanical stresses that occur here.  Forces exceeding seven-times body weight are experienced around the knee cap with activities such as running and jumping.  In general, females are more prone to patellofemoral syndrome because of the way their legs are aligned compared to their male counterparts.

The front of the knee is a complex structure and is very sensitive. A number of factors can contribute to runner’s knee and patellofemoral syndrome, including:

  • Maltracking of the kneecap
  • Excessive training or overuse
  • Flat feet
  • Tightness, imbalance, or weakness of thigh and hip muscles
  • Usually it’s a combination of factors.  Most of my patients have some imbalance between strength and flexibility combined with the other factors listed above.    


  • Stay in shape. Good general conditioning is important to controlling and preventing patellofemoral pain. If you’re too heavy, you may need to lose weight to avoid overstressing your knees.
  • Stretch. Before running or any other exercise, first do a 5-minute warm up, followed by stretching exercises. Stretching, particularly in the face down position (prone), will help keep the supporting structures around the front of the knee flexible and less likely to be irritated with exercise. For example, when lying prone, grab the ankle of the affected leg with one hand, and gently stretch the front of the knee. Stretch before and after exercise.
  • Increase training gradually. Avoid sudden changes in the intensity of exercise. Increase force or duration of activities gradually.  The 10% rule is good to keep in mind (increase duration or intensity of activity 10% per week).
  • Use proper gear. Use running shoes with good shock absorption and quality construction. Be sure that shoes fit properly and are in good condition.
  • Use proper running form. Lean forward and keep your knees bent. Also, try to run on a clear, smooth, resilient, even, and reasonably soft surface. Never run straight down a steep hill. Walk down it, or run in a zigzag pattern.


The RICE formula always comes in handy as first-line treatment for aches and pains in runners:

  • Rest. Avoid putting stress on the painful knee.  This can range from using crutches to switching activities depending on the severity of symptoms.  Rest is a “must” for the majority of runners that I see in my office, but they difinitely don’t like to hear it!
  • Ice. Apply cold packs or ice wrapped in a towel for short periods of time (15 to 20 minutes), several times a day.  
  • Compression. Use a simple knee sleeve with the kneecap cut out so that it can provide support and gentle compression.
  • Elevation. Keep the knee elevated when possible especially if you notice swelling.

The RICE formula works even better if you combine it withnonsteroidal anti-inflammatory medications (NSAIDs) such as aspirin or ibuprofen.  If your knee does not improve, see your doctor.  Physical therapy is the cornerstone treatment for issues that don’t resolve with RICE.  The whole idea of physical therapy is to work on “striking the balance between strength and flexibility.”  Other things such as appropriate shoe wear, orthotics or insoles for your shoes, and more advanced braces and straps are also sometimes part of the treatment equation

And for those of you who have “bad knees” but simply want to keep running, we have other options.  Injections to decrease inflammation (cortisone) or provide lubrication for the knee (viscosupplementation) are sometimes helpful.  In some cases, surgery is indicated to smooth rough cartilage, replace missing cartilage, stimulate tendonitis to heal, or help the knee cap to track better.  We can even transplant cartilage in runners who have developed a “pothole” in their knee. 

And finally, we are using things like Platelet Rich Plasma (PRP) and Stem Cells to treat arthritis and cartilage breakdown in some of our runners who refuse to hang up their shoes…

So there you have it – have fun and stay fit as you run your own safe running program this spring and summer.

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Dr. Joseph Guettler is an orthopedic surgeon who specializes in sports medicine, as well as surgery of the knee, shoulder, and elbow. He is also a proud member of the MOS Team.