Knee Pain When Running or Squatting? What the Research Says About Physical Therapy

If your knee hurts when you run, squat, jump, climb stairs, or train legs, you’re probably looking for a simple answer.

Maybe you’ve been told to rest. Maybe someone recommended new running shoes, foam rolling your IT band, strengthening your VMO, or avoiding deep squats.

The problem?

Knee pain is rarely that simple.

At Ground to Overhead Physical Therapy, we work with runners, lifters, CrossFit athletes, and active adults throughout Chapel Hill, Durham, Cary, and the Triangle who want to keep training while getting rid of persistent knee pain.

The good news is that the research gives us a much clearer picture of how common forms of knee pain should be managed.

For conditions such as patellofemoral pain (PFP), the strongest evidence supports an active approach built around exercise, education, appropriate activity modification, and—when appropriate—individualized changes to running or movement mechanics. (BJSM)

What Is Patellofemoral Pain?

Patellofemoral pain is pain around or behind the kneecap that is commonly aggravated by activities such as running, squatting, stairs, jumping, and prolonged sitting.

You may have heard it called runner’s knee.

Importantly, patellofemoral pain is not simply a problem with your kneecap being “out of place,” and it isn’t automatically caused by weak glutes or poor movement mechanics.

Current evidence suggests that PFP is multifactorial. Training load, strength, movement patterns, physical capacity, previous injury, and individual pain sensitivity can all contribute.

That’s why two people with similar-looking knee pain may need very different rehabilitation programs.

And it’s also why simply treating the painful spot isn’t always enough.

What Actually Helps Knee Pain?

1. Exercise Is the Foundation of Rehabilitation

The most consistent finding across the research is surprisingly simple:

Exercise works.

Current best-practice recommendations identify exercise therapy and education as the foundation of treatment for patellofemoral pain. Exercise can target the knee, hip, or both depending on the individual’s presentation. (BJSM)

This doesn’t mean everyone with knee pain needs the same three exercises.

A runner may need progressive single-leg strength and calf capacity.

A weightlifter may need to progressively reload deep knee flexion.

A CrossFit athlete may need to modify jumping volume while rebuilding quadriceps strength.

The goal isn’t simply to make the knee “stronger.”

The goal is to build enough capacity to tolerate the activities you actually want to perform.

2. Train the Quads and Hips—But Don’t Chase One “Magic Muscle”

Older approaches to knee rehabilitation often focused heavily on the VMO or isolated quadriceps exercises.

The current evidence supports a broader approach.

Combining hip- and knee-focused exercises can improve pain and function more effectively than knee exercises alone in people with patellofemoral pain. (BJSM)

That doesn’t mean your gluteus medius is necessarily “weak” or that your knee pain is caused by your hip.

Instead, hip and knee musculature are part of the system that controls and produces force during running, squatting, jumping, and cutting.

Depending on the individual, rehabilitation may include:

• Squats

• Split squats

• Step-downs

• Leg presses

• Knee extensions

• Lunges

• Hip abduction exercises

• Single-leg strength work

• Calf strengthening

• Plyometrics and jumping

• Running-specific strength work

The specific exercise matters less than progressively exposing the patient to the loads they need to tolerate.

3. Stop Thinking of Rest as the Main Treatment

One of the biggest mistakes active people make with knee pain is swinging between two extremes:

“Push through everything.”

or

“Stop training until it goes away.”

Neither approach is ideal for many overuse-related knee problems.

Instead, rehabilitation often involves load modification.

That may mean temporarily reducing:

• Running mileage

• Running intensity

• Hills

• Jumping volume

• Squat volume

• Training frequency

• Range of motion

• Heavy eccentric loading

while maintaining other forms of training that your knee can tolerate.

Then, as your symptoms and physical capacity improve, the goal is to progressively rebuild the activities that matter to you.

This is especially important for athletes.

If your goal is to run a half marathon, return to CrossFit, compete in weightlifting, or play recreational sports, simply getting your knee comfortable with walking isn’t enough.

Your rehabilitation should eventually resemble the demands of your sport.

4. Your Running Mechanics May Matter—but There Isn’t One “Perfect” Running Form

If you’re a runner with knee pain, you’ve probably heard that you need to change your foot strike, stop heel striking, or completely change your running form.

The reality is more nuanced.

Running mechanics can influence the amount and distribution of load experienced by the knee. One strategy that has been studied extensively is increasing running cadence.

Laboratory studies have found that increasing cadence can reduce patellofemoral joint loading in runners with patellofemoral pain. (PubMed)

Recent systematic-review evidence also suggests that a moderate cadence increase—often around 5–10%—can reduce certain biomechanical measures associated with lower-extremity loading. (PubMed)

But that doesn’t mean every runner with knee pain should immediately increase cadence by 10%.

A good physical therapist looks at the entire picture:

• Current running volume

• Pace

• Hills

• Cadence

• Stride characteristics

• Strength

• Previous injuries

• Training history

• Symptoms during and after running

• Recovery between sessions

Sometimes changing cadence helps.

Sometimes changing training volume is more important.

Sometimes the best intervention is simply getting stronger.

5. Foot Orthoses and Other Treatments Can Help—When They’re Appropriate

Exercise should generally be the foundation of rehabilitation, but that doesn’t mean other treatments have no role.

Current best-practice recommendations support using interventions such as prefabricated foot orthoses, taping, manual therapy, and movement or running retraining when they fit the individual’s presentation and preferences. (BJSM)

The important distinction is that these interventions are generally adjuncts, not replacements for active rehabilitation.

For example, an orthotic may help reduce symptoms enough for someone to tolerate their strengthening program.

Taping may provide short-term symptom relief that allows a patient to exercise more comfortably.

Manual therapy may temporarily improve symptoms or movement.

Those tools can be useful.

But the long-term goal is to improve your ability to move, train, and perform without continually depending on passive treatment.

What About Iliotibial Band Syndrome?

If your pain is located on the outside of your knee, the diagnosis may be different.

Iliotibial band syndrome (ITBS) is a common running-related condition characterized by lateral knee pain.

It should not simply be lumped together with patellofemoral pain.

Research on ITBS is less definitive than the evidence base for patellofemoral pain, but current evidence supports an active rehabilitation approach that commonly includes hip-focused strengthening and progressive return to running. (PubMed)

Importantly, older theories that attribute ITBS to one isolated weakness or a single biomechanical fault don’t fully explain the condition.

Like many running injuries, ITBS appears to involve multiple factors.

What We Don’t Recommend

If you’re dealing with persistent knee pain, you don’t necessarily need to:

• Stop all exercise

• Avoid squatting forever

• Avoid running indefinitely

• Foam roll your IT band aggressively

• Find the “perfect” shoe

• Strengthen only your VMO

• Stretch everything around your knee

• Completely eliminate knee-over-toe movement

• Rely exclusively on passive treatments

Instead, we want to understand why your knee is currently struggling to tolerate the demands you’re placing on it.

Then we build that capacity back up.

A Better Way to Think About Knee Pain

Think about your knee like an athlete’s training system.

You have a certain amount of capacity.

You also have a certain amount of demand.

Problems often arise when demand consistently exceeds capacity.

For example:

Capacity:Your knee can currently tolerate 10 miles of running per week.

Demand:You suddenly start running 25 miles per week.

Or:

Capacity:Your knee can tolerate 100 controlled squats with your current strength and recovery.

Demand:You suddenly add high-volume squatting, box jumps, running, and lunges to the same training week.

The answer isn’t necessarily to eliminate the activity.

The answer is to modify the demand and increase capacity until the two match again.

That’s the foundation of sports physical therapy.

When Should You See a Physical Therapist for Knee Pain?

Not every episode of knee pain requires physical therapy.

But an evaluation is particularly useful when:

• Knee pain keeps coming back

• You can’t run without symptoms

• Squatting or lifting is consistently painful

• Pain is limiting your training

• You’ve already tried rest without lasting improvement

• You aren’t sure what is causing your symptoms

• You’re returning to running or sport after an injury

• You’re worried that exercise is damaging your knee

• You want to return to a specific sport or performance goal

A good evaluation should go beyond simply finding the spot that hurts.

At Ground to Overhead Physical Therapy, we look at the relationship between your symptoms, training demands, strength, mobility, movement, and sport-specific requirements.

For a runner, that may include running mechanics and training load.

For a lifter, it may include squatting, pulling, Olympic lifting, and lower-extremity strength.

For a CrossFit athlete, it may include running, jumping, Olympic lifting, and high-volume conditioning.

The goal isn’t just to make your knee feel better on the treatment table.

The goal is to help you confidently return to the activities you actually care about.

Knee Pain Physical Therapy in Chapel Hill, Cary & Durham, NC

If you’re looking for physical therapy for knee pain in Chapel Hill, NC, or sports physical therapy in the Triangle, Ground to Overhead Physical Therapy works with active adults and athletes who want more than generic rehabilitation exercises.

We provide individualized, evidence-informed physical therapy for runners, lifters, CrossFit athletes, and active people dealing with knee pain and other orthopedic injuries.

If knee pain is keeping you from running, squatting, lifting, jumping, or training the way you want to, schedule an evaluation and let’s figure out what’s actually limiting you.

References

1. Crossley KM, van Middelkoop M, Callaghan MJ, et al. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions. Br J Sports Med. 2016;50(14):844-852. (BJSM)

2. Neal BS, Lack SD, Bartholomew C, Morrissey D. Best practice guide for patellofemoral pain based on synthesis of a systematic review, the patient voice and expert clinical reasoning. Br J Sports Med. 2024;58(24):1486-1495. (BJSM)

3. Nascimento LR, Teixeira-Salmela LF, Souza RB, Resende RA. Hip and knee strengthening is more effective than knee strengthening alone for reducing pain and improving activity in people with patellofemoral pain: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2018;48(1):19-31.

4. Neal BS, Lack SD, Lankhorst NE, Raye A, van Middelkoop M, Barton CJ. Risk factors for patellofemoral pain: a systematic review and meta-analysis. Br J Sports Med. 2019;53(5):270-281.

5. Bramah C, Preece SJ, Gill N, Herrington L. Is there a pathological gait associated with running injuries? A systematic review. Sports Med. 2018;48(11):2441-2452.

6. Sanchez-Alvarado A, Bokil C, Cassel M, Engel T. Effects of conservative treatment strategies for iliotibial band syndrome on pain and function in runners: a systematic review. Front Sports Act Living. 2024;6:1386456. (PubMed)

7. Foch E, Brindle RA, Pohl MB. Lower extremity kinematics during running and hip abductor strength in iliotibial band syndrome: a systematic review and meta-analysis. Gait Posture. 2023;101:73-81. (PubMed)