Is Running Bad For Your Knees?

Spend enough time in the average weight room and you might walk away thinking that running is the root of all exercise evil: It does a lousy job at burning fat. It’s less exciting than C-SPAN and, haven’t you heard, it messes up your knees. But if you’ve been avoiding the treadmill based on the word of the guy who seems to live under the squat rack, you might want a second opinion.

Running is far from immune to scrutiny, as this very site has proven multiple times over, but the negative long-term impact it has on the joints is often wildly overstated, if not flat-out wrong. As Janet Hamilton, an exercise physiologist and run coach with Running Strong in Atlanta puts it, “Joints are meant to move. And running is arguably one of the most natural movements you can do as a human.” Hamilton points to research that consistently shows running—and running a lot—actually improves knee health.

She’s not wrong: In one study of nearly 100,000 runners and walkers, researchers found that frequent running did not increase the risk of osteoarthritis—the most common form of arthritis, linked to wear and tear of protective cartilage and connective tissue—even among seasoned marathoners. In fact, researchers found that osteoarthritis was half as common in runners as it was in walkers. Of course, there’s a good chance that the running group was self-selecting—that people who didn’t experience knee pain in the first place were the ones who stuck with running. But it still says something that after a seven-year followup among people who had no osteoarthritis to begin with, it was walkers who developed knee problems in greater numbers.

X-ray evidence suggests that osteoarthritis is actually more common in soccer players and weightlifters than it is in long-distance runners, says Leigh-Ann Plack, a physical therapist and advanced clinician with the Hospital for Special Surgery in New York City, and author of a review on running and osteoarthritis.

Hamilton thinks the lower risk of osteoarthritis could be due to the fact that running stimulates the production and circulation of synovial fluid, a type of lubricant that nourishes the joints, as well as the fact that runners—at least, more serious ones—tend to maintain better strength and mobility in their muscles. When researchers at Brigham Young University stuck runners with needles to extract and study their synovial fluid, they found that 30 minutes of running decreased the fluid’s levels of inflammatory proteins linked with poor cartilage turnover. (It’s worth noting that the study was small, and the researchers were unable to get enough synovial fluid from about half of the subjects.)

So if running is so great for your knees, then why do so many people complain of knee clicks, or a condition literally known as runner’s knee? Partly because the vast majority of people who run have a combination of muscle imbalances and less-than-stellar form, says James Gladstone, an orthopedic knee surgeon and sports medicine specialist at Mount Sinai Hospital in New York City. “The best thing you can do for your knees as a runner,” he says, “is make sure to have proper mechanics and proper muscle balance.”

Running can also backfire in people with pre-existing osteoarthritis or knee damage, since it can stress the knee with up to eight times the force of walking, according to one review. In healthy subjects, this can be a good thing—stress causes microscopic damage to the cartilage, and as you recover, the tissue grows back stronger (it’s like building muscle in that way). However, that stress can be too much for already-osteoarthritic knees to handle, Gladstone says.

Even if you’re not prone to injury, following these guidelines will help you stay that way the next time you step on a treadmill:

How To Prevent Injury From Running

Get Stronger
Strength coaches like to say, “Running doesn’t make you strong. But you need to be strong to run.” This Insta-worthy expression has some truth to it, largely because running is a repetitive exercise that involves a select group of lower-body muscles, a limited range of motion, and only hits one plane of movement, Plack says.

For example, running does little to train the hip abductors, the muscles on the outside of the hip that help you move from side to side, Hamilton says. As a result, many runners have underdeveloped abductors. Research shows that weak abductors can lead to IT Band syndrome—a persistent ache on the outside of the knee that just won’t quit. “Begin running only after you have built a foundation of strength—muscle and tissue strength, not just aerobic strength—to support it,” Hamilton says. Once you start running, perform some form of multi-planar(forward-and-backward, side-to-side, and rotational) strength training at least a couple of times per week.

Deal With Underlying Issues
If you have issues with your skeletal alignment, such as flat feet, high arches, knock knees, bowed legs, or leg-length discrepancies, get some help from a trained professional, Hamilton says. The same goes if you’ve had knee aches, plantar fasciitis, or any other exercise or running problems in the past. A physical therapist or kinesiologist can help get to the bottom of any issues and address their underlying causes, which will help prevent any issues—knee or otherwise—from cropping up mid-run, she says.

Hire a Coach
Running is a natural movement, but most people don’t do it correctly. For example, excessive stride length is a common form misstep that can put excessive stress on the knees, Plack says. So if you want to run faster, you shouldn’t try to take bigger strides. Schedule an appointment with a physical therapist, kinesiologist, exercise physiologist, or certified run coach to evaluate and shore up your running form. Some knee-protecting strategies may be as simple as shortening your stride or as involved as identifying and strengthening muscle imbalances, she says.

Take It Slow
Make the transition to running gradually and build your endurance slowly over time, Hamilton says. “Aerobic conditioning responds relatively quickly, but it may take longer than that for your muscles, tendons and ligaments to adapt to the training load.”

As a general rule, experts recommend not increasing your total training load (distance + speed + duration + frequency) any more than 10 percent per week. Hamilton notes that some runners may need to stay closer to five percent. Some might be best off increasing only every other week. “It’s also good to avoid applying too many versions of ‘more’ in any given workout,” she says. “In other words, do hills or a longer workout rather than hills and a longer workout.”

Schedule Recovery Time
“Overload plus recovery equals adaptation and improvement. Overload without recovery equals injury,” Hamilton says. The exact amount of recovery you need depends on multiple factors including your fitness, how hard you’re pushing yourself, your current running and strength training routine, and your overall physical and mental stress levels, she says. High-tech strategies such as heart rate variability can help you determine when your body needs light exercise or no exercise at all. But “listening to your body” will also get the job done.

Find the Right Shoe
Much like rotating the tires on your car, mixing up the running shoes you use throughout the week can lower your risk of injury, according to research from the Sports Medicine Research Laboratory in Luxembourg. Researchers believe cycling through shoes mixes up the stress placed on your joints and tissues, which prevents overuse injuries and strengthens a wider range of muscles. Hamilton recommends buying your shoes from a running specialty store that has software designed to record and analyze how various shoes affect your running form and pattern.

Don’t Train Through Pain
“If something hurts, step back and investigate the situation and address the underlying cause of the symptom—not just the symptom itself,” Hamilton says. Generally, any pain that is sharp or strikes the joints is reason to cut your workout short. Sometimes the cause is obvious: Maybe you tripped over a crack in the sidewalk or got cocky and pushed your workout too hard too fast. If it isn’t, or if the pain isn’t completely gone in a couple of days, seek professional help, she says. Again, a physical therapist with a specialty in running will be your best bet for identifying the problem and solution.

By K. Aleisha Fetters for TONIC

The NBA May Be Pushing its Tallest Players to the Point of Injury

A doctor’s theory about this season’s injury epidemic

These days, the NBA and its faithful fans are searching for unicorns. I’m talking about a virtually mythical combination of physical attributes in one person for the purpose of pure full-court magic.

Once upon a time, players were assigned roles and positions based on their heights. Shorter people were supposed to shoot, pass, and dribble while those more vertically gifted were expected to lumber around the basket. This was all basketball 101.

Somewhere in recent years though, unicorns emerged and the dogma was upended. Since the advent of the NBA, the average height of players has increased from 6’3” to what it is today: 6’7”. As height as increased, the league’s skill and athleticism has also ballooned. And so, tall players (power forwards and centers) are no longer gangly giants dependent entirely on their inches to make an impact. Now, they’re expected to be sublime and omnipotent too. But while they’re tasked to bring their A-game to the court for every game, the anatomical confines of their knees may really not be about that life.

For a piece in the New Yorker, Vinson Cunningham described the preternatural brilliance of the Milwaukee Bucks’ Giannis Antetokounmpo, who’s the archetype of the NBA’s unicorn. “All game, he did things that—given his almost seven-foot frame and long, stretchy limbs—he shouldn’t, by rights, be able to do, but which have become staples of the diet he offers to fans: deceptive hesitations before journeys into the paint; flicked fifteen-foot turn-around jumpers; easy sprints to regain a position on defense that seemed hopelessly lost.”

Here’s where it gets dangerous: when coaches realize these men aren’t mythical beings but instead real people with real body limitations. This season, DeMarcus Cousins of the Pelicans ruptured his left Achilles tendon and Kristaps Porzingis of the Knicks tore his left ACL. Both injuries ended their seasons.

Injuries and injury scares have also punctuated the careers of other uncanny talents: Joel Embiid, Ben Simmons, Kevin Durant, and Anthony Davis. A 2014 tally by FiveThirtyEight found that taller players have missed a larger percentage of games than their shorter counterparts, with those 7’0” or taller being absent for 24 percent of their games. Cousins’ and Porzingis’ injuries have occurred in a season already teeming with hurt players. A recent count found that 3,798 games had been missed due injuries, up 42 percent from the same point last season.

There are theories about this year’s injury epidemic, which is perplexing at a time of unprecedented advances in medicine and science. Some have noted that the rise is merely part of a random year-to-year fluctuation, devoid of any meaningful explanation. Others are suspicious of the NBA’s adoption of a more frenetic style of play, which increases the probability for injury because of all the additional movement up and down the court. There have also been rumblings from executives and coaches about this year’s shortened preseason and the suboptimal conditioning and regular season preparation that resulted.

In recent seasons, coaches have not been passive about their lengthened injured lists and have implemented their own remedy to prevent injury: the Did Not Play-rest (DNP-rest). Though a study has discerned no effect of this on playoff injury risk or performance, players are simply held out of entire regular season games and instructed to sit on the sidelines and rest. While new league rules have caused a dip in the practice, it still persists.

Any temptation to blame the schedule is unfounded. Playing back-to-back games or playing four games in five days alone has not been associated with a heightened injury risk. Game injuries do occur more often in away games, which may be attributed to NBA travel schedules that affect sleep patterns and thus reaction times.

According to Dr. Brian Cole, an orthopedic surgeon at Rush University and team physician for the Chicago Bulls, this season is no different from others. “Game schedule density, back-to-backs, things of that nature have not really been shown to make a difference,” he says. “Other than a statistical anomaly, we have no data that it is otherwise. This population of players is likely no different than the year before.”

Dr. Cole notes that the NBA is still not good at injury prediction models and assimilating all the independent variables that go in it. Assessing the risk for any player, let alone these unprecedented unicorns, thus remains an unknown. He adds, “I have this intuitive feeling that as they get bigger, stronger, faster, and taller, I think the body can only do so much and that may be a factor.”

In the end, the principles of human anatomy, physics, and physiology may prove to be nonnegotiable. In his forthcoming book Human Errors, scientist Nathan Lents writes about our imperfect evolution to bipedalism and the anatomy that was left most vulnerable. “The anatomical adaptation to upright walking never quite finished in humans. We have several defects that are the result of this failure to complete the process.

Lents comments specifically on two overburdened parts: the anterior cruciate ligament (ACL), which connects the femur (thighbone) to the tibia (shinbone) and resides in the middle of the knee, and the Achilles tendon, which attaches the calf muscle to the heel of the foot. Because of our evolutionary straight-leg arrangement, “the Achilles tendon has become the Achilles’ heel” of the entire ankle joint and the ACL endures “much more strain than it is designed to.”

Stressed to their unnatural max by the sudden changes in speed, momentum, and direction of today’s larger players, the ACL and Achilles tendon capitulate—and this is what might have happened when Porzingis and Cousins were felled to the ground earlier this season.

In a running sport that involves acceleration and deceleration and a high degree of unpredictability, the risk is perpetual. One study found that even asymptomatic NBA players carry one or more abnormalities within the knee on MRI. As renowned trainer Tim Grover wrote in Sports Illustrated, “The same muscles, ligaments, tendons, and joints are used over and over again, in the same direction, the same angles, the same motions…At some point the human body just says, ‘Enough.’”

As we wander further into this new frontier on basketball in which players like Antetokounmpo do the outrageous with facility, there will be more work for NBA officials, doctors, trainers, and support staff to do. While injury prediction models still lag behind and bad luck will intermittently reign, league schedulers should redouble their efforts to assess risk and interventions should be deployed to encourage more multi-sport athletes at the high school level. And given the unremitting demands of a 82-game schedule, fatigue management, recovery, and sleep have to be optimized. At this moment of unknowns, this is all we have in order to ensure that we’re not destroying the unicorns for the sake of a little magic.

By Jalal Baig, MD  for TONIC

When An Injury Means You’re Going To Miss Out

By Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Dealing with the psychology of sports injury can be difficult for many athletes, and there are several ways to deal with these issues effectively
  • With the right mindset and demonstration of small gains in recovery, you can turn the injury into an asset and in many instances come back better than you were

I’m starting to see reports of some elite professional soccer players who will miss the upcoming World Cup due to recent injuries. The injury recovery process will require months of rehab, meaning they will not be ready in time to participate. For many athletes, whether an elite professional or a recreational athlete, dealing with the possibility of missing a really important event or even having to retire from sport can create significant psychological challenges.

The process of dealing with feelings associated with sport injury is in some ways similar to the phases of grief a person may go through with life threatening issues. In medical school one of our required readings was On Death and Dying by Swiss psychiatrist Dr. Elisabeth Kübler-Ross. She outlined 5 stages: denial, anger, bargaining, depression, and acceptance. These stages don’t always happen in this order, nor does everyone go through each. Sport injuries are a long way from dealing with a terminal illness, but her model is still a useful framework and is used by many sports psychologists.

One sport psychologist I’ve heard lecture and really like is Dr. Jim Taylor. Here’s how I recall he applied the basic framework of Dr. Kübler-Ross’s model to sport injury recovery:

  • This is where you just can’t believe you’re actually injured. Many athletes with ongoing nagging injuries in this stage try to power through and continue. If this goes on for months it’ll affect performance and often leads to a minor injury becoming major. Dr. Taylor writes that getting stuck here is dangerous. Action step: If you’re having ongoing issues affecting performance get proper evaluation and a plan for recovery.
  • Why did this happen to me? Injustice, unfairness, or outright anger. This is incredibly common especially if you’re about to miss a once in four years or once in a lifetime event. It’s fine to be angry for a while, but then move on. Action step: If you really can’t move on you should seek professional help.
  • In the sports injury world this often involves what we refer to as “doctor shopping”. This is the process of seeking multiple opinions in hopes of finding one who says “it’s no big deal, go ahead and play”. A second opinion is a good idea but a fourth or fifth opinion is usually draining and counterproductive. My advice, shared by every sports medicine colleague I know: get a couple of opinions, go with what you’re most comfortable with, and move on.
  • Sometimes recovery can take many many months, and in some instances even a short recovery time can push someone into depression. As an orthopedic surgeon, this is out of my area of expertise so if we see cues from our patient, or if family members voice concerns we’ll quickly refer for proper psychological evaluation and treatment. Depression is usually treatable and nothing to be ashamed of. Get help quickly.
  • For an athlete, reaching acceptance can be turned into an asset. Once you get to this point the best athletes will use the injury as an opportunity to correct issues that may have led to the injury in the first place and actually come back from injury better. Getting to this mindset is incredibly important, and once you get there you’ll usually find that physical recovery comes faster. Action steps: make small and measurable gains with assistance of your physical therapists and athletic trainer. Small successes build on each other and will motivate you to get to your peak potential.


Lessening Knee Replacement Pain Through Dry Needling

By Brian Rog and Charles Matt Huey, PT, MPT, Cert. MDT, CMTPT for ATI Physical Therapy

Lessening Knee Replacement Pain Through Dry Needling

Often times, the inevitable postsurgical pain and discomfort following a procedure like a total knee arthroplasty (commonly known as a knee replacement) is a mystifying variable we cannot seem to escape – even with the inclusion of opioids. However, what if we told you, that this pain could be lessened considerably without medication, would you believe us?

Major advancements in technology have allowed the operational side of procedures to go as seamless as possible; however, the short- and long-term effects of post-surgery pain still appear to be unavoidable. Well, that was the original belief. Thanks to research, a lesser known, yet growing in popularity, practice called myofascial trigger point dry needling or dry needling, is playing a vital role in minimizing post-surgery pain when it is most severe. Data suggests that patients who undergo dry needling prior to a total knee replacement endure less pain after intervention as compared to those who do not.

Before we take a closer look into these findings, it is important to understand what exactly dry needling is, its role in helping to mediate knee injuries, how dry needling differs from acupuncture, and what conditions it is most appropriate for treating.

But first, let’s brush up on the origins of knee pain as this will help draw a better connection to dry needling and knee pain.

Trigger points and knee pain

Most patients undergoing knee replacement surgery have endured some form of pain through the process, or experience decreases in their functional abilities. Because of this, simple activities like walking or standing become troublesome, so people tend to do less of both thinking they will be better off. Unfortunately, this inactivity attributes to several physiology responses such as decreased endurance, stamina, weakness and loss of motion.  There may also be a change in gait pattern, which can cause the muscle fibers to shorten or over-lengthen, leading to trigger points.

Herein lies the problem. These trigger points then begin to harvest pain due to the sarcomeres (functional unit of striated muscle) moving closer together, causing a decrease in blood flow and oxygen saturation, which makes the muscle area very acidic. And when there is an acid build-up in the muscles, you’ll experience knots, fatigue and muscle burn.

Since most researchers’ efforts zero in on the causes of the pain, like bone-on-bone contact in the knee, these trigger points, which have a large role in the resurrection of pain, often go unnoticed. It is at this moment that we start to understand the value of techniques like dry needling.

What is dry needling?

Dry needling is a technique for the treatment of myofascial pain (contraction knots) and dysfunction in musculoskeletal areas where muscles are typically denser. Due to the sensitive nature with treating areas of deep tissue, dry needling helps target these areas without the discomfort or bruising commonly experienced through hands-on techniques. The goal of dry needling is to help the body relax and increase blood flow at locations of discomfort. By doing this, the muscles will contract, which will allow for improved functionality and decreased pain.

Some of the more common conditions dry needling helps to remedy deal with sprain/strain injuries, chronic pain conditions, chronic tension-type headaches, pressure build-up in the muscles, and nerve compression conditions.

Differences between dry needling and acupuncture

Like dry needling, acupuncture uses similar anatomically specific (non-injection) filiform needles to help reduce pain. However, the approach and ideologies of the procedures are where we start to see the similarities fade.

Dry needling involves the insertion of a needle into soft tissues with the aim of decreasing muscle tissue tension and improving musculoskeletal function.

Acupuncture, on the other hand, uses needles to manipulate the balance and flow of the body’s energy meridians. Doing this stimulates the body to produce its own pain-relieving endorphins, which help to promote healing and restore health.

Dry needling and post knee replacement surgery pain

Earlier in the story, we talked about a study that suggests dry needling can help lessen post-surgery pain in total knee replacements. Fascinating, right?

Here’s what we know, the study observed 40 patients undergoing a total knee replacement. The 40 subjects were unknowingly randomized to a ‘true’ dry needling group or to a ‘sham’ group where the procedure mimicked a dry needling intervention, but was not true dry needling. Each of the participants were examined for myofascial trigger points by an experienced physical therapist 4–5 hours before surgery. Immediately following anesthesiology and before surgery started, subjects in the ‘true’ group were dry needled in all previously diagnosed trigger points, while the ‘sham’ group received no treatment in their myofascial trigger points. This is where it gets good. The results concluded that subjects in the ‘true’ group had less pain after their surgery and showed significant differences in the need for immediate post-surgery opioids. So that begs the question, why isn’t dry needling more commonly recommended to individuals undergoing a total knee arthroplasty? The answer is simple. Awareness!

Muscles after surgery

Using knee replacement cases as our example, dry needling is beneficial as it helps to reduce trigger points that either developed prior to the surgery or afterwards.  During the surgery, tissue is pulled and moved around which can be traumatic to the tissue.  It will then respond by shortening and becoming painful. The patient may also not want to start moving again right after the surgery due to pain or other complications from the surgery. Again, lack of activity will cause decreased strength, shortening of the muscles, reduced endurance, etc., ultimately leading to trigger points.  The patient’s body mechanics may have changed as well causing the muscle to fire and move in incorrect patterns, which also lead to trigger points.

Dry needling and long-term opioid use

As compared to opioids, dry needling is a safe and effective alternative to controlling musculoskeletal pain especially in chronic pain patients. Opioids have a long list of side effects and can lead to spiraling dependencies. Opioids work by binding to receptors in the brain and body, however, there are limits to the number of receptors that can be utilized. Once every receptor has something bound to it, any additional increase in dosage has no effect. By steadily increasing the dosage level means that the medication is not working and other options need to be explored.

Studies have found longer relief of pain is best managed through dry needling as compared to wet needling (lidocaine injections) and medication. The use of dry needling is just one component in controlling pain. A skilled therapist will use needling to remove any painful trigger points but also direct the patient in a beneficial exercise program to continue to decrease and control pain.

Does ATI Physical Therapy offer dry needling treatment?

Dry needling is currently offered at select ATI Physical Therapy locations across our more than 750 clinics nationwide. To see if dry needling is available to your area, we recommend calling your nearest ATI clinic for more information.

Chicago Dogs Select Midwest Orthopaedics at Rush as Team Physicians

The Chicago Dogs LogoMidwest Orthopaedics at Rush has been selected as the official team physician for Chicago’s newest professional baseball team, the Chicago Dogs. MOR team physicians will be responsible for pre-season physicals and treating players’ orthopedic injuries or conditions during the season.

“The Chicago Dogs take great comfort knowing that our players will be cared for by the fifth-ranked orthopedic group in the country, including Drs. Brian Cole, Gregory Nicholson, and Jeremy Alland,” explains Chicago Dogs owner Shawn Hunter. “MOR physicians are national leaders in the field of sports medicine and we are proud to partner with them as we enter our inaugural season in Chicagoland.”

MOR doctors serves as team physicians for the Chicago Bulls, Chicago White Sox, and Chicago Fire Soccer Club, among others. They are using advanced techniques and have many subspecialty orthopaedic physicians on staff who  diagnose and treat even the most complicated and rare orthopedic conditions.  MOR physicians are supported by a professional staff of nurse practitioners; physician assistants; athletic trainers; physical and occupational therapists; and other administrative personnel.

“Our staff is looking forward to supporting this young baseball team and keeping them healthy and on the field,” Dr. Cole says. “Caring for pro athletes is our ‘sweet spot’ and we are ready to help them safely reach their goals this season.”

About The Chicago Dogs
The Chicago Dogs are the newest member of the American Association of Independent Professional Baseball. Home games are played at the state-of-the-art Impact Field located at 9800 Balmoral Avenue in Rosemont, Ill. For schedule and ticket information, visit

About Midwest Orthopaedics at Rush
MOR doctors are team physicians for the Chicago Bulls, Chicago White Sox, Chicago Fire Soccer Club and Joffrey Ballet, among others. They are known for treating patients with orthopedic conditions, ranging from the most common to the most complex. The group’s reputation as a leader in specialized orthopedic patient care, education and research has been recognized by many national publications. U.S. News & World Report ranks the orthopedic program at Rush University Medical Center, Chicago, as No. 5 in the nation and it is the highest ranked program in Illinois and Indiana.