"My knee hurts when I run. I feel it right around my kneecap. It came out of nowhere, but I've been ramping up my mileage because I've got a marathon in three or four months." That's almost word for word what Julie told me a few months ago. She's a runner here in the Washington, DC area, training for the Marine Corps Marathon this October. She doesn't race marathons often, so she wanted to get a jump on her training.
If that sounds familiar, you're not alone. Pain at the front of the knee is the single most common reason runners come to see us, and it's something we treat all the time at Norton Physical Therapy.
For the record, getting an early start is smart. Most runners who don't log high mileage or race often need about 20 to 24 weeks to prepare. The most important stretch is the first 12 weeks or so , the base period, when your soft tissues and joints gradually adapt to the stress of running, so that when the hard training kicks in over the final two to three months, your body is ready for it.
When most people get knee pain, they reach for glute work: clamshells, monster walks, bridges. Those exercises help and have a real role in recovery. But the piece that's most often overlooked is strengthening the quadriceps, the muscle group on the front of your thigh that attaches directly to your kneecap.
What's really going on?
When you run, your quads absorb the force of each landing and stabilize your leg. They work hard — handling forces of roughly four to six times your body weight with every stride. When the knee starts to hurt, working the quads feels counterintuitive, because it usually means some form of squatting, which can be painful in the early stages and uncomfortable even later on.
Here's the catch: research has consistently shown that knee pain actually inhibits the quadriceps — the muscle shuts down and weakens — and the people who get the best outcomes in physical therapy are the ones who rebuild that strength.
So why would something that causes a little discomfort be the thing that fixes the problem? Quad-based exercises gently load the kneecap. When that load is appropriate, the body responds with an enhanced healing process, and with the right recovery and enough time, the tissue adapts and gets stronger. Most people are surprised to learn that cartilage, fascia, and joints adapt just like muscle. The first time you pick up a weight it feels hard and you might get sore, but done consistently over time, you get stronger.
What can you do about it?
Here's the progression we use in the clinic. Start where your knee is comfortable and move up only as symptoms allow.
- Test it with a squat. A regular squat is our favorite way to gauge knee comfort and strength. If you can do 10 squats with little to no pain, you've likely outgrown it as a test. Most people with patellofemoral pain can't do that comfortably, so we scale the movement back — a wall sit (quarter-depth or full), or a step-up.
- If pain is severe, hold off on squatting. In those cases we lean on posterior-chain work like bridges, single-leg deadlifts (RDLs), and step-ups. These load the quad gently while strengthening the muscles around the knee.
- As pain settles, raise the demand. A favorite of mine is a lateral squat on a slider, or a reverse lunge on a slider. Both move the knee through a small range while emphasizing control — less strain on the kneecap, more confidence in the tissue.
- Then add range and load. Fortunately, running only requires about 45 degrees of knee flexion, so you don't need to squat deep. The goal is a single-leg squat to at least that depth, and from there we start adding weight.
If your knee isn't improving in two to four weeks, or the pain starts spreading up or down the leg, that's a sign something else may be going on and it's worth a closer look. I'd recommend reaching out to your physician or a local running-focused physical therapist like us — we're in the Georgetown neighborhood of Washington, DC.
If you remember one thing, make it this: glute work helps, but the primary treatment for patellofemoral pain in runners is quad strengthening. If you're sore, start small with a wall sit; as you feel better, build toward something that looks more like running, like a single-leg squat. Be patient — these issues resolve, but they take time and usually some adjustment to your training and running form.
How we help?
If you're a runner in Washington, DC dealing with knee pain, we'd be happy to jump on a quick call to figure out what's going on and whether we're the right fit to help you get back to running comfortably.
We have treated 1,000's of runner's in Washington DC who want professional expertise in running medicine and physical therapy. We put all runner's thought a specialized movement screen that pick's up on any weak areas to target, coupled that with a runeasi 3D running gait analysis and combine our vast experience working with runners to apply the best plan possible!
Contact us to get started right away!
Evidence Supporting This Article
- Lack S, et al. "Hip and Knee Strengthening Is More Effective Than Knee Strengthening Alone for Reducing Pain and Improving Activity in Individuals With Patellofemoral Pain: A Systematic Review With Meta-analysis." Journal of Orthopaedic & Sports Physical Therapy, 2018. Confirms that knee (quad) strengthening drives improvement, and that adding hip strengthening produces even better outcomes than focusing on the hips/glutes or the knee in isolation. https://www.jospt.org/doi/10.2519/jospt.2018.7365
- "Effects of physical therapist–guided quadriceps-strengthening exercises for the treatment of patellofemoral pain syndrome: a systematic review." NCBI / Database of Abstracts of Reviews of Effects. Found strong evidence that quadriceps-strengthening exercises, with or without other interventions, reduce pain and improve function in patellofemoral pain. https://www.ncbi.nlm.nih.gov/books/NBK241764/
- "Conservative treatment of patellofemoral pain: effectiveness of strength exercises compared to other treatments — a systematic review with meta-analysis." PMC, 2024. Supports strengthening exercise as a first-line conservative treatment for patellofemoral pain. https://pmc.ncbi.nlm.nih.gov/articles/PMC12533450/