New evidence to challenge old ideas…
Long has there been a negative association between osteoarthritis (OA) and running – with
common assumptions including running being a cause of knee OA, as well as running being
a cause for provocation of symptoms. This blog will look to explore these ideas and give you
a greater understanding of where to head forward if you’re a runner with OA.
A study conducted in 2018 followed 1203 participants aged over 50 (mean age 63.2) with
knee OA over a 10-year period (Lo et al., 2018). This study found that running in fact
improved knee pain in these patients, and on follow-up x-rays, didn’t display any progression
Another study compared 45 long-distance runners to 53 non-runners over an 18-year period
(Chakravarty et al., 2008). This study found after an 18-year period, the runners compared to
the non-runners did not have more prevalent OA (20% vs 32%), nor more cases of severe
OA (2.2% vs 9.4%).
Two possible mechanisms have been proposed as to why running isn’t being shown to cause,
or exacerbate, symptoms of OA. Miller (2017) proposed that cumulative load (total load on
the joint from running), which is actually low in running, is a more important factor for OA
risk and exacerbation than peak load (when the stress on the joint is at its highest). Secondly,
it is known that running actually conditions the cartilage (cushioning between the joints) to
withstand the mechanical stresses of running.
Finally, more recently, Dong et al. (2020) systematically reviewed (the strongest type of
study available) the effect of running on knee cartilage. The study compared the short and
long-term effects of running on a group of runners, versus non-runners. The study concluded
that only short-term and very minor adverse effects were seen on the runners compared to the
non-runners, but these adverse effects resided very quickly when sufficient and appropriate
recovery was undertaken. As such, the study advocated the importance of regular loading on
the knee joint to ensure the cartilage maintains its normal function and integrity.
While this is positive, this does not mean that everyone with OA will be able to run or return
to running. Individuality of your pathology and pain responses means everyone will react to
exercise, or running, in different ways. But with the latest research coming to hand, it may be
worth considering Physiotherapy intervention before you throw out your running shoes.
What Physiotherapy strategies/advice can help?
As with any exercise, we need to gradually implement this new ‘stimulus’ in order to control
for pain provocation. For those with OA – beginning with a short walk/run program may be a
starting point to introduce the structures in the knee to some running load without causing
Similarly, with any exercise intervention, we need to be mindful of cumulative loads. As
previously stated, Miller (2017) proposed cumulative load as more important for OA risk. As
such, Physiotherapists can help to ensure you are following appropriate ‘loading’, suggested
through strength & conditioning principles, which may include appropriate acute:chronic
loading (for instance, total distance covered in a week in reference to the total distance
covered in the month) and subsequent appropriate rest periods (Plisk & Stone, 2003). A
running diary that tracks the date, distance and pain scale of each run is a simple way for a
Physiotherapist to understand your load management.
All runners need to implement appropriate recovery in order to manage their tissue loading,
but more important will it be if you’re a runner with OA. Particularly as we age – longer the
amount of recovery between runs may need to be. Consider the previous load management
diary – is pain before and after a run better when the runs are further spaced apart through the
week? Combine this with other recovery modalities such as using ICE post runs, and other
gentle aerobic activities combined in-between (walking, swimming, cycling, etc).
Strength training: GLA:D program
Our Physiotherapists can assist you in developing an appropriate strength program to
strengthen and support your hip and knee, which is shown to have great outcomes for people
with hip and knee OA. More specifically, the GLA:D program, developed in 2018 at LaTrobe
University, is a structured exercise program designed specifically for patients with hip and
knee OA. The program combines an element of education, aerobic exercise and hip and knee
strengthening and has been shown among other endorsements to induce pain reduction of
36% as well as improve joint confidence (Skou & Roos, 2017).
Other: cross-training, terrains/hills, footwear, biomechanics and cueing
As previously alluded to – mix running with other forms of exercise in-between runs as
tolerated to build tissue resilience (walking, swimming, cycling, etc).
No research to date has suggested running on particular terrains for individuals with knee OA
– although it would be reasonable to suggest first beginning on softer, non-undulating
surfaces, before experimenting beyond this.
Footwear advice is a larger topic, but simple guidelines would involve throwing out old
(worn) runners and avoiding drastic changes in footwear in respect to the ‘heel-toe drop’ (the
angle between the heel and front of shoe) and minimalism (cushioning), which has the ability
to load tissues in different capacities (Paterson et al., 2018).
Limited literature has investigated running biomechanics alterations in runners with OA
specifically, although we know some running biomechanical characteristics including the
likes of overstriding and excessive hip adduction (crossover-stepping) have the ability to
increase loading through the knee (Souza, 2016). Similarly, cueing to alter running
biomechanics hasn’t been investigated specifically in knee OA runners, but may include
simple cues such as taking ‘shorter, faster steps’, or ‘stepping either side of an imaginary
line’ (Willy et al., 2016). These adjustments should only be made in consultation with your
How can we help?
Whether you’re looking to return to running, improve your symptoms when running, or
simply improve your symptoms and confidence during every-day activities, our
Physiotherapists have excellent knowledge around OA to help you both understand and
facilitate what’s required to achieve your goals.
Please call us on 52772151 or book online and let us help you to get started towards achieving your goals.
Chakravarty, E. F., Hubert, H. B., Lingala, V. B., Zatarain, E., & Fries, J. F. (2008).
Long distance running and knee osteoarthritis: a prospective study. American
journal of preventive medicine, 35(2), 133-138.
Dong, X., Li, C., Liu, J., Huang, P., Jiang, G., Zhang, M., . . . Zhang, X. (2020). The
effect of running on knee joint cartilage: a systematic review and
meta-analysis. Physical Therapy in Sport.
Lo, G. H., Musa, S. M., Driban, J. B., Kriska, A. M., McAlindon, T. E., Souza, R. B., .
. . Hochberg, M. C. (2018). Running does not increase symptoms or structural
progression in people with knee osteoarthritis: data from the osteoarthritis
initiative. Clinical rheumatology, 37(9), 2497-2504.
Miller, R. H. (2017). Joint loading in runners does not initiate knee osteoarthritis.
Exercise and sport sciences reviews, 45(2), 87-95.
Paterson, K. L., Bennell, K. L., Wrigley, T. V., Metcalf, B. R., Campbell, P. K., Kazsa,
J., & Hinman, R. S. (2018). Footwear for self-managing knee osteoarthritis
symptoms: protocol for the Footstep randomised controlled trial. BMC
musculoskeletal disorders, 19(1), 219.
Plisk, S. S., & Stone, M. H. (2003). Periodization strategies. Strength & Conditioning
Journal, 25(6), 19-37.
Souza, R. B. (2016). An evidence-based videotaped running biomechanics analysis.
Physical Medicine and Rehabilitation Clinics, 27(1), 217-236.
Willy, R., Buchenic, L., Rogacki, K., Ackerman, J., Schmidt, A., & Willson, J. (2016).
In‐field gait retraining and mobile monitoring to address running biomechanics
associated with tibial stress fracture. Scandinavian journal of medicine & science in sports, 26(2), 197-205.