Each week, MyHealthNewsDaily asks the experts to answer questions about your health.
This week, we asked exercise experts: Is running bad for your knees? Their answers have been edited and condensed for space.
Dr. Lewis Maharam, fellow of the American College of Sports Medicine:
That’s an old wives tale. Your parents decide if you’re going to have arthritis or not you’ll have arthritis — it’s genetic.
Jogging, or running, itself will not cause the arthritis. If you already have arthritis, and you have bone and bone contact, and no cartilage in your knee, running will make it worse.
If you’re doing harm to your knees, if you’re running and jogging and the pain becomes such that it alters the way you run, then it’s time to stop and go see your doctor.
In fact, running helps future arthritic patients actually be more active in their later years. The compressive motion, helps bring more fluid in your knees and keeps them moving.
Dr. Stephen G. Rice, Director of Sports Medicine at Jersey Shore University Medical Center:
Not everyone who runs is destined to get arthritis.
The knees take a lot of pressure. The hipbone is a very nice ball and socket, and the ankle is set up in a good way, but the knees can take nice, happy cartilage and start to break it down.
The condyles of the femur (thigh bone) are round, and rest on the flat surface of the tibia (shin bone). There is always a place where the two bones touch bone-to-bone (as a basketball on a table would do). Both of these bones have a coating of hard, shiny, firm cartilage at the ends, enabling the bones to glide on one another.
The C-shaped meniscal cartilage in the knee is more spongy — like your nose or ear. It helps stabilize the thigh bone on top of the shin bone, and provides cushioning as we run, jump or walk.
But over time, the meniscal cartilage can wear down and lose its sponginess, and thus not absorb as much shock. The bones then pound on each other harder, and from that friction, arthritis develops and worsens.
The lighter you are, and how well you land your feet are also important. Not everybody hits the ground with the same relative amount of force: Some people walk softly, and some sound much louder walking by. For those people who hit heavier, that extra force is an issue. Then there’s the issue of whether people’s weight is healthy.
So, yes you can begin to develop arthritis from the pounding from running. However, the person who is active and fit and moving around is doing the most active defense against arthritis. There’s a happy medium between whether you run smart, slowly building up your endurance, and stay active, and if you put extra force on your knees.
Some people who are genetically set up for arthritis, and no matter how well they run, they will end up developing arthritis.
Chris Troyanos, certified athletic trainer and the medical coordinator for the Boston Marathon:
Inherently, running is good and healthy for most people, but it’s a matter of how you get started in it, and it’s a matter of slow progression.
However, there are body types out there that are not conducive to running. For example, people who are excessive pronators have the inside part of their feet drop inward more than it should when they’re running. That causes stress on the feet and knees, so their bodies are naturally not great shock absorbers.
People who have hyperextending knees — technically the term is genu recurvatum — are also going to have trouble running. Those who have some of these issues can run, but they may not be able to run more than a mile or two.
When you’re looking at starting a running program, one you might want to start with a walking program first, then make the leap to an easy running program.
As you go through these steps of increasing your activities, it’s important to listen to your body. If you are getting knee pain when you go from 5 to 7 miles a day, that could be your threshold for you.
If you have any type of existing pain or discomfort in your legs, it’s not smart to keep running.
Dr. Jon Schriner, faculty member at Michigan State University
The jury is still out. Some say yes running is bad for the knees, some say no.
It’s well known that heavier people are at higher risk for arthritis.For every pound of weight a person carries – whether it’s in their body or they put it on in a pack – they have four pounds on the knee when running. In other words, if you weigh 100 pounds, there are 400 pounds of force on the knee with each foot strike.
It can also depend on how the person is running: how high you lift your foot off the ground and how you strike the ground. Joggers tend to strike with less force, runners tend to have longer strides and put more force on the knee.
There are many other factors that go into how running can affect your knees such as weight, body structure, shoe selection, and technique – we refer to it as going too far too fast too soon.
I don’t think there’s enough evidence that says running within non-abusive limits causes arthritis. But then it’s a question of what’s abusive limits? We could say that running ultra-marathons could put people at risk, and new marathoners I see often run too far, too fast, too soon and end up with knee problems, but other marathoners don’t have problems.
There are some people who say at that age 40 or 45, people should combine running with bicycling or some other cross training, so they’re not just pounding their knees, and that seems to work well to keep people physically fit, cardio-fit and keeping the knees in action.
In general, if your knees are healthy and you follow a reasonable approach to running you should not injure your knees. If you have knee pain for any reason you should seek the advice of a qualified Sports Medicine Physician before it becomes serious.
Dr. Michelle Wolcott, associate professor at the University of Colorado School of Medicine:
If you haven’t had an injury, a broken bone or a ligament injury where you are predisposed to arthritis, then your chances of creating arthritis are minimal.
We know that weight-bearing exercise, such as running, helps prevent osteoporosis and osteoarthritis. Repetitive weight bearing and motion are good for the joints, and running essentially does that.
Extra pounds may or may not make it harder on your knees when you run. If you have lean weight — and by lean weight I mean muscle weight — it will help support your joints and bones. But if it’s weight from fat that is non-functional, it will just add stress on the knees.
Obesity definitely plays a role in osteoarthritis of the knees. When you put too much force on cartilage – a common place is underneath the knee caps – the pressure on your knees is greater. And that pressure on the cartilage will break it down over time. This is why obese people are more prone to osteoarthritis.
There is a huge genetic component to osteoarthritis as well. If you have a family history of osteoarthritis and have knee pain, running may not be the best exercise for you.
If you are not predisposed to osteoarthritis, and have healthy knees and are of healthy weight, then running doesn’t affect your risk for knee arthritis. That’s a huge misconception and one that I fight all the time. There’s absolutely no evidence to the idea that running alone causes osteoarthritis. People who claim that running caused their knee pain often already had had injured knees.
- Is Running Bad For Your Joints And Bones?
- Running and Bone Problems
- How to Run Properly
- Put Those Shoes On: Running Won’t Kill Your Knees
- How to run forever
- What 6 Joint Docs Say About Running
- Running Doesn’t Cause Arthritis
- Running When Injured Causes Serious Damage
- Proper Training Takes a Lot Longer Than You Think
- Rest Days Are Key to Protecting Your Knees
- How You Run Is a Factor in Developing Knee Problems
- All Runners Need Strength Training
- The Surface You Run on Matters
- The Right Shoes Are Crucial
- Every Run Should Include Stretching
- How to Treat and Prevent Runner’s Knee
- Is Running Good or Bad for Your Knees?
- Running May Be Good for Your Knees and Hips, and Marathons Aren’t Necessary
- Is Running Bad For Your Joints?
- Running: Can it damage your knee?
- Running and bone spurs in the knee
- Physical activity and knee joint space narrowing
- Jogging and cartilage damage in the knee
- The overwhelming benefits of physical activity
- Caution – Talk to your doctor
Is Running Bad For Your Joints And Bones?
Running is a favourite exercise for most people to improve both physical and mental health. When running, we use many parts of the body at one time, especially the joints and bones. Many people think that running can adversely affect joints and bones and cause some injuries to the joints and bones. However, this thought is completely wrong.
In fact, there has been a lot of research showing that proper running is beneficial for our bones and joints.
If you run correctly, it will not affect the joints and bones but bring multiple positive impacts on the health. In this article, we will bring you the necessary information to demonstrate that running is not dangerous for your joints and bones.
Photo Credit: 123RF
Running and Bone Problems
Running is bad for the joints and bone is a misconception that many people are suffering from. Some people suppose that regular running is the leading cause of osteoarthritis. However, researchers found no association between running and osteoarthritis. Instead, factors such as obesity, family history, high age, and myopathy or joint pain are potential risks for osteoarthritis in the future.
Many studies have demonstrated that running could help you fight osteoarthritis. The reason is that regular running will make muscles tend to be more firm, thus reducing the pressure on the joints. The researchers also concluded that athletes had lower knee pain rates than those who did not run, regardless of their age.
Also, runners often have a low BMI which is body mass index, used to measure the body’s lean mass through height and weight.
Running is a great way to improve your joint and bone health. Not only will you have less risk of osteoarthritis, but regular running will also help you repel osteoporosis which affects over 200 million people around the world. Fortunately, running exercise is the ideal training strategy to promote and maintain one’s health. A study done at the University of Missouri found that running was effective in improving bone density.
Photo Credit: 123RF
The work of researchers at the University of Camilo José Cela-Spain, published in the Journal of Applied Physiology, showed that running helped protect bone density, especially for the elderly. They also found that people who regularly run have significantly higher heel bone density than those who are less active.
How to Run Properly
To avoid unfortunate injuries and achieve excellent results from running, you should run correctly. Here are seven guides to running correctly.
1. Keep Your Eyes Straight Ahead
To run properly, you should keep the head up and eyes looking straight forward, avoid looking down.
2. Keep Your Posture Properly When You Are Running
- When running you should keep the body relaxed, the centre of the body slightly forward, but still have to keep the chin up, the shoulder rested and the back straight.
- Do not hold your neck or shoulders as that limits your breathing, making you more tired.
- Do not fold the end too much or lean forward too much as it makes the centre of body unbalanced.
3. Keep Your Hands On The Waist
For beginners, they often do not pay attention to hand postures when running. They usually put the hands over their chest, which can be seen when the runner begins to feel tired. Brandishing the hands too high not only has no effects on your running but also makes you tired quickly.
The correct hand posture for runners is to keep the hands at on the waist and fold hands about 90 degrees. This right posture will help improve your strength quite well.
Photo Credit: 123RF
4. Relax Your Hands
When running, keep your arms and hands relaxed and free. Do not put pressure on your arms and hands as that not only have no benefits for running but also makes you strained and tired at the arms, shoulders, and neck quicker.
5. Proper Landing
If you are a long-distance runner, do not think about feet touching the ground with your toes or heels. Because if you are landing with the toes, that will make your legs muscles tense and tired.
This is a cause of vertical leg pain. If you are grounding with the heel, it means that your stride length will be longer and the centre of the body will be on the knees. It does not help you to run faster but also makes you at high risk of injuring.
In case you have the habit of landing with the heel, you should remove it. The best way to landing is to touch the ground with the middle of the foot and then press to the tip of the foot to gain momentum to run better.
6. Don’t Lift Your Legs Too High
Runners often have the habit of raising the feet too high when running. But this is a wrong running posture of legs. To make your feet proper when running, you should keep your feet as close to the ground as possible, limiting your knees too high. That will save you energy when running.
Photo Credit: 123RF
7. To Step Short When Running
Perhaps you often think that long, vast strides will help you run faster. But the reality is that whether you run long or short steps, your speed will not change. Runners with quick steps not only can limit the normal injury but also have stable the heartbeat when running. However, you need to practice to be able to run with short steps effectively. Mastering short-step running will be the premise that helps you to run better.
Running is an excellent way to boost your joints and bones’ health. However, not everyone can run. If you have been injured in the past, whether it is muscular injury, cartilage or ligaments, you are at risk for further damage if you run.
We hope that you will have proper identification of the impact of running on your joints and bones and understand the correct running technique to get the best performance when running.
Put Those Shoes On: Running Won’t Kill Your Knees
Paul Rider runs on Mulholland Drive in Los Angeles, March 25, 2011. Researchers say a moderate running regimen is actually beneficial for the joints of people with healthy knees. Dennis J. Provost for NPR hide caption
toggle caption Dennis J. Provost for NPR
Yes, it’s true: Jogging, long thought to hurt knees with all that pounding and rattling around, may actually be beneficial for the complex and critical joint. There are caveats, though, especially for people who have suffered significant knee injury or are overweight. But for the most part, researchers say, jogging for your health seems like a good idea.
David Felson, a researcher and epidemiologist at Boston University School of Medicine, says past concern about jogging and knees centered on the continuous impact of the foot to the ground and suggestion that it caused degeneration of the knee and the onset of osteoarthritis. But when researchers actually studied the impact of running on knees, he says, that’s not what they found.
“We know from many long-term studies that running doesn’t appear to cause much damage to the knees,” he says. “When we look at people with knee arthritis, we don’t find much of a previous history of running, and when we look at runners and follow them over time, we don’t find that their risk of developing osteoarthritis is any more than expected.” Both types of studies agree, says Felson, that recreational running doesn’t increase the risk of arthritis.
‘Running Is Healthy For The Joint’
In one study, Swedish researchers found that exercise, including jogging, may even be beneficial. Felson describes how researchers took one group of people at risk of osteoarthritis and had them engage in exercise, including jogging. The other group didn’t exercise. After imaging the joints of the participants in both study groups, they found that the biochemistry of cartilage actually appeared to improve in those participants who were running. Felson says that suggests that “running is actually healthy for the joint.”
Long-term studies show that running doesn’t appear to damage knees. But researchers caution that if you’ve had knee surgery or if you’re more than 20 pounds overweight, you shouldn’t jump right into an intensive running routine. Dennis J. Provost for NPR hide caption
toggle caption Dennis J. Provost for NPR
Long-term studies show that running doesn’t appear to damage knees. But researchers caution that if you’ve had knee surgery or if you’re more than 20 pounds overweight, you shouldn’t jump right into an intensive running routine.
Dennis J. Provost for NPR
Jonathan Chang, an orthopedic surgeon in Alhambra, Calif., says that exercise appears to stimulate cartilage to repair to minor damage. It could be that the impact of body weight when the foot hits the ground increases production of certain proteins in the cartilage that make it stronger, he says. This is similar to the way exercise, in particular weight-bearing exercise like jogging, increases bone and muscle mass.
According to Nancy Lane, director of the UC Davis Center for Healthy Aging who specializes in rheumatology and diseases related to aging, scientists are now starting to understand that there is some loss of cartilage annually after a certain age. Some doctors think cartilage loss begins after age 40.
But, according to Lane, “if you have a relatively normal knee and you’re jogging five to six times a week at a moderate pace, then there’s every reason to believe that your joints will remain healthy.”
An Indicator Of Activity
That’s great news for Paul and Lyra Rider, avid joggers who live in the Hollywood Hills in Los Angeles. Jogging on Mulholland Drive, they say, offers fantastic views — along with a relatively flat route. Paul, 46, jogs a seven- to eight-minute mile — not as fast as his younger days. Lyra jogs a bit slower. She enjoys the exercise, health benefits and simplicity of jogging. “You don’t need lots of fancy equipment, and you just feel great when you’re done,” she says.
Lane did some of the very first studies of runners and knees while she was a resident at Stanford University.
“We wanted to answer the important question of whether, if you continued to run into your 50s and 60s and even 70s, you also ran the risk of damaging the knees,” she says. The answer, she says: absolutely not. And there was an extra bonus: While enthusiasm for jogging seemed to diminish as people hit their mid-60s, Lane says they were still more inclined than the non-joggers to get out and exercise.
From NPR’s ‘The Human Edge’
“They were active doing other activities, like walking, yoga, water aerobics,” she says. “We found that as these people aged, not only did they feel better about themselves, but their quality of life was better and they tended to actually live longer” than the non-joggers.
So, the message for joggers like the Riders, who hope to be jogging all their lives, is a hearty two thumbs up.
A Few Caveats
Lane cautions that if you have suffered a knee injury, especially one that required surgery, running can actually increase your risk of knee arthritis. So can routinely running really fast — at a five- or six-minute-mile pace — or running in a marathon. Lane’s best advice? Running in moderation, at an eight- to 10-minute mile pace, for about 40 minutes a day.
But if people are more than 20 pounds overweight, Lane says they shouldn’t start off with an intense running regimen.
“I have them walk and walk until they’re to a point where I think their body mass is reduced enough that it won’t traumatize their joints,” she says. Otherwise, significantly overweight joggers run the risk of that extra weight stressing the knee to the point of inflammation, the formation of bony spurs and accelerated cartilage loss.
How to run forever
I often get this question: “Doc, does running hurt my knee?” The answer is no. Injury hurts your knee.
If you have healthy knees, you can run forever. If you have a cartilage injury, a torn meniscus or an unstable knee joint, then the knee will wear out faster than normal.
If you’re a runner, or if you’re considering taking up running, the following data and insights will help you protect your knees.
Running produces peak impact forces on the knee of one to three times your body weight depending on a host of factors such as the smoothness of your gait, your running technique and the surfaces that you run on. Heel striking increases the peak forces, midfoot-landing produces lower peak forces, as long as the running shoe is soft enough to permit compression of the arch tissues of the foot. Interestingly, when running is compared to walking, since you take fewer steps per mile when you run, the total amount of force that the knee sees is often less in smooth running than in walking. So technique and surfaces really do matter.
The normal knee has articular cartilage that varies from 1.69 to 2.55 millimeters thick. The articular cartilage covers the ends of the bones in all joints and provides the smooth-bearing surface. The slickness is roughly five to 10 times slicker than ice sliding on ice. When you injure the articular cartilage or get arthritis, this smooth surface begins to get rougher. As the surface roughens, there is a dramatic increase in the friction between the surfaces in the joint. This increased friction leads to gradually increasing wear of the joint surfaces. During activities, such as running, the damaged surfaces can’t absorb and distribute the impact force from your foot hitting the ground as well as normal joint surfaces can. So higher peak forces on an injured knee produce damage.
The normal knee also has two meniscus cartilages, which distribute forces and stabilize the knee. If torn or missing due to injury or surgery, the impact forces are concentrated on a smaller area of the knee leading to more rapid wear.
Lastly, the normal knee has ligaments that stabilize the knee. Unstable knees lead to tearing of the meniscus and just like a car out of alignment wears out its tires, the abnormal motions of the unstable knee lead to an acceleration of the wear patterns of the joint surfaces.
The assertion that normal knees can run forever is backed up by observations of huge animals such as African elephants weighing more 13,000 pounds that can run extraordinarily fast, and live for 60 years without joint arthritis.
In addition, we have found that people are able to return to running even after injury by repairing their articular cartilage, and replacing damaged meniscus cartilage or ligaments with donor tissue. A long-term outcome study of some of our biologic joint replacement patients found that many were able to run again, after fearing that they had reached the end of the road.
Nothing beats running. Running provides the endorphins, pheromones, adrenaline and testosterone so efficiently that the addiction to running and the bliss from it is very difficult to replace. Running provides a health benefit on a cost basis and time analysis that any health care program would envy.
If you have healthy knees, run, but make sure you run efficiently with a smooth technique involving short strides, midfoot landing, well-fitting running shoes and soft surfaces. If you have injured knees, repair them or find the running bliss in other sports, but don’t miss out.
What 6 Joint Docs Say About Running
The idea that running is bad for your knees is a popular fitness myth, according to many doctors and surgeons who are experts in joint health. In fact, there are a lot of misconceptions about running and its impact on the body. We asked six joint experts to explain the real story behind running and your joints. Here’s what they said:
Running Doesn’t Cause Arthritis
Contrary to popular belief, running does not cause arthritis or osteoarthritis later in life. “I think people have this misconception because we draw these conclusions from people who have run for a long time who have knee pain,” says Karen Morice, MD, an attending physician in the department of rehabilitation medicine at Montefiore Medical Center in New York City.
“But you know what else happens over time? People get older, which is exactly when arthritis all over the body happens — running or not. So it could be coincidence,” Dr. Morice says. Shazia Bég, MD, a board-certified rheumatologist at the University of Central Florida College of Medicine in Orlando, agrees. “Most studies show there isn’t any correlation between running and developing osteoarthritis. The biggest risk factor for developing osteoarthritis is age,” says Dr. Bég. “Think of your body like a car: The more miles you put on it, the more there’s a chance to damage it, there’s more wear and tear. The more miles you put on your joints, the more chance there is for degeneration,” Bég adds. It’s also genetic, she says, so you’re at a higher risk if there’s a history of arthritis in your family — whether you’re a runner or not.
Running When Injured Causes Serious Damage
“There’s never been a study to show that running on its own generates arthritis or directly causes any kind of damage to the knee,” says Tracy Ray, MD, an associate professor of orthopedic surgery at Duke University School in Durham, North Carolina. “If you already do have some damage to your knee, however, you can generate further damage — but the same is true for any kind of weight-bearing activity, like playing basketball,” Dr. Ray says. He explains that this holds true for the person who runs nine miles a week as well as the person who logs 40 miles a week. “It really depends on the existing health of your knee. If you haven’t had an injury, or you don’t have a diagnosis or X-ray that indicates wear and tear on the cartilage, there’s nothing that would indicate that it’s unsafe for you to train,” adds Ray.
Proper Training Takes a Lot Longer Than You Think
All experts we spoke to agreed that a proper training program that builds up gradually over time is essential for protecting the knees from injury and joint trouble. “There are training programs online that indicate that you can get up off the couch and run a 5k in six weeks, or do a half marathon for charity in three months, and some people do get away with that,” says Ray. “I see the people that don’t, and there are a lot,” he says. “Remember, cardiovascular health comes along faster than your cartilage and joints,” Ray adds.
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If you’re a beginner, don’t try to push yourself too hard too fast, which can lead to overuse injuries such as stress fractures. “To start out, if you never ran before, you might want to start out with walking/running intervals,” says Leonardo Oliveira, MD, an assistant professor of medicine at the University of Central Florida College of Medicine in Orlando. Dr. Oliveira suggests walking for four minutes then jogging for one. Progress a little bit each week, and rest every other day. “This helps the body adapt to activity,” he says.
Rest Days Are Key to Protecting Your Knees
Rest days to let the body recover are a part of any distance-running training program, and for good reason, says Oliveira. “If you’re training for a marathon or a half-marathon, you’ve got to build up the mileage slowly and not do a long run every day, back to back,” he says. You might do a three-mile jog one day, then the next day do some cross training to build up leg strength and hip strength; maybe the next day do your longer run, and then take a day off, he says. “ depend on your level of experience and your goal, using pain and soreness as your guide,” he says. “If you’re very sore the day after a run, it would not be wise to go for a run that day,” he says.
How You Run Is a Factor in Developing Knee Problems
When it comes to knee pain and running, “technique is important — the biomechanics of how someone runs,” says Guillem Gonzalez-Lomas, MD, assistant professor of orthopedic surgery at New York University Langone Medical Center. “How their foot strikes the ground; if they pronate when they foot-stride; if they don’t have strong hip stabilizers — those are all important,” Dr. Gonzalez-Lomas says. “There are ways to modify most of these things dynamically, like making slight modifications to your stride or orthotics, which might shift the weight a little bit when your foot hits the ground,” he says.
All Runners Need Strength Training
“Running is a high-level physical activity, so your back, abs, and legs need to be strong,” says Morice. That’s why building good core strength is essential for all — but especially serious — runners. The stronger your muscles, the less impact on your joints. You’ll also decrease the likelihood of injury, experts say. Oliveira suggests including strength training two to three times a week to build core strength so that the body is best equipped to handle the impact of running. “The stronger your muscles, the less impact will go into your joints as you’re running, and the lower your chance will be for injury or damage,” Oliveira says.
The Surface You Run on Matters
“Running on the concrete is the worst surface you can run on,” for joint wear and tear, according to Joseph Herrera, DO, assistant professor of rehabilitation at the Icahn School of Medicine at Mount Sinai in New York City. “The most ideal is running on soft surfaces such as tracks; asphalt is another good alternative. In general, the softer the surface, the more joint-friendly it is,” says Dr. Herrera. On the flip side, many runners may notice that a softer surface slows them down. “While softer surfaces are not as efficient for running and can slow you down, it will tend to absorb some of the impact and be a little easier on the joint,” says Gonzalez-Lomas. “The best artificial surfaces are those newer, rubberized running tracks. They have turf designed to give your feet some cushioning and spring-back,” says Gonzalez-Lomas.
The Right Shoes Are Crucial
While you may not be able to control the surface you run on, you can control your footwear. “Finding the right shoes will take a little bit of trial and error. The staff at running stores may not be medical professionals, but they have a very good idea of what type of shoe works for what kind of person,” says Gonzalez-Lomas.
Oliveira suggests going to a specialty running store and getting fit for comfortable running shoes that match your specific foot type. He also recommends changing your running shoes every 300 to 400 miles. “As time goes on, you lose cushion and ability of a shoe. Many runners I know buy two pairs at once and switch off every day, which slows the breakdown of the cushion and coil in the shoe,” he adds.
Every Run Should Include Stretching
“The day after a run, gentle stretching is key,” says Oliveira. You should also stretch before and after every run regardless of the length of your run. Post-run stretching is very important, he adds. “The muscles I really recommend you stretch the most are the quadriceps, hamstrings, gluts, and calves,” says Oliveira. Ice is another way to relieve soreness and alleviate muscle and joint stress after a run.
Most people who have injured the cartilage in their knees are better off not running or jumping for the rest of their lives, but rather relying on other low-impact exercises to maintain physical fitness.
At your knee, two bones meet and are held together by four bands, two on the outside and two on the inside. The ends of bones are soft, and they are protected by cartilage, which is a tough, thick white gristle. Cartilage can break when it is subjected to a strong force such as might happen when you are hit on the knee or unexpectedly step into a hole. Once broken, cartilage will never heal. Doctors can remove loose pieces, but they cannot make broken cartilage whole again.
A rise in the cartilage covering the upper bone in your knee fits into a depression in the cartilage covering the lower bone. When you break off some of the cartilage, the upper and lower cartilage does not fit together as well, so the joint loses stability and any hard force on the joint can knock off more cartilage. If you have knee cartilage damage and you continue to run and jump, you can expect more and more cartilage to be torn loose. Eventually, when all of the cartilage has been knocked loose, the exposed bone will hurt all the time and the knee may need to be replaced.
If you have damaged the cartilage in your knee, you are better off never running or jumping. Try riding a bicycle, swimming and walking only if it doesn’t hurt when you do it. You should also be given exercises to strengthen the muscles that control your knees.
Q: Should I wear ankle weights while I jog? R. E., Duluth, Minn.
A: Wearing ankle weights when you run or walk increases your chances of injuring yourself. Every muscle in your body is balanced by other muscles that perform opposite functions. Muscles that bend your knee are opposed by those that straighten your knee, and muscles that raise your knee are opposed by those that lower it.
The quad muscles in the front of your upper leg raise your knee during running and walking. Your hamstrings in the back of your upper leg lower your knee. Opposing muscles develop strength proportional to the activity that uses them. Bicycle racers and hockey players have quad muscles and hamstrings that have approximately equal strength. Most runners and walkers have quad muscles in the front that are stronger than the hamstrings in the back. If their quads are more than twice as
strong as the hamstrings, they are more likely to tear the hamstrings.
Ankle weights add weight to your lower leg, causing your quad muscles in the front of your upper leg to work much harder to lift the heavier weight against gravity. This causes the quad muscles to become significantly stronger than the hamstrings, and it increases your chances of injuring both your quads and your hamstrings.
Your quads are more likely to be injured because they have to lift a much heavier weight when you raise your knees during running and walking. Your hamstrings are more likely to become injured because the quads pull with a greater force against them.
Q: I’m 58 and was recently diagnosed with diabetes. My doctor told me to start an exercise program. How can exercise help a diabetic? — H. D., St. Louis
A: Most people who develop diabetes after the age of 50 can control their disease just by going on a low-fat diet, exercising and losing weight. Every cell in your body is like a balloon filled with fluid. On the surface of each cell’s membranes are little hairlike projections called insulin receptors. Insulin cannot do its job of driving sugar from your bloodstream into cells until it first attaches to an insulin receptor. When your body can’t make enough insulin, your blood sugar level rises and you develop diabetes, but the vast majority of people who develop diabetes after age 50 have enough insulin to control their blood sugar levels. Their disease occurs when their cells arenot able to respond to insulin because they don’t have enough receptors.
The number of insulin receptors is determined by how much fat you have in your body and how much fat you eat. When cells are full of fat, they have fewer receptors. Emptying fat from cells markedly increases the number of insulin receptors on their surface.
You reduce the amount of fat in your body by eating less fat, losing weight and exercising. There’s a good chance that when you exercise and lose weight, your blood sugar level will return to normal.
Dr. Mirkin is a practicing physician in Silver Spring specializing in sports medicine and nutrition.
How to Treat and Prevent Runner’s Knee
Undoubtedly one of the most common running ailments, runner’s knee or patellofemoral pain syndrome (PFPS), can hamper your training or leave you completely sidelined.
The pain associated with runner’s knee is located under, slightly above or below the kneecap. It generally worsens when athletes run uphill, downhill or up and down stairs. A popping sensation is sometimes audible. In the worst cases, the knee may swell.
More: How to Prevent Knee Pain and Injury
A term used to describe a number of knee issues, runner’s knee often occurs because of an increase in mileage. While some harriers will experience sporadic pain, others have problems nearly every time they add miles. The condition can also be related to poor running form and core strength.
“A lot of these injuries result from motion or mobility problems in the hip or low back,” explains Dr. Aaron LeBauer, a physical therapist based in Greensboro, North Carolina. “Or it can be an instability issue because of lack of core engagement. If you have an imbalance that causes the leg to be unstable, it may be a hip control issue.”
Indeed, strength and mobility imbalances will have a greater effect on the body over increased mileage, resulting in issues like runner’s knee. The dilemma is you often won’t know you have these imbalances until your knee starts to nag you. At this point, it becomes important to back off and identify where the injury originated.
“The biggest problem is that people don’t listen to their bodies and they run through pain,” says LeBauer. “Running through sharp, shooting pain just makes the issue worse; end up in my office because they keep running rather than resting or seeking treatment earlier.”
More: How to Treat and Prevent Common Running Injuries
What causes it: “There’s a muscle that attaches to the back of the shin bone and that muscle wraps around the inside of the ankle bone and helps to control the foot when it pronates , and also helps during push-off to propel you forward,” Ferber explains. Shin splints happen when there’s repetitive trauma to the connective tissue that attaches this muscle to the tibia bone, says Gallucci. The tissue breaks down, becomes inflamed, and sometimes, scar tissue forms during the healing process, “which produces pain and tightness.”
How to fix it: Getting running sneakers with more cushioning is a good start, but shoe choice is just a minor part of this, Ferber says. “The true fix is strengthening.” He tells patients to follow a heel raises program (check it out here) to strengthen the calves and ankles.
3. Plantar fasciitis
What it is: Plantar fasciitis causes a stabbing pain on the bottom of the foot near the heel. “It’s usually a little bit stiff at the beginning of a run and then the pain goes away. Then, it’s a little stiff when you finish,” says Ferber. “But it hurts first thing in the morning. That first step out of bed is excruciating at the heel. It can take 15 to 30 steps to get it warmed up and to go away, and then you kind of forget about it.”
What causes it: The plantar fascia is a thick band of connective tissue that runs along the sole of the foot from the toes to the heel. Its job is to support your arch, Ferber says. “It gets stretched every time the foot comes down, and rung back out as the foot pronates,” he explains. It’s designed to be thick enough to withstand these forces, but too much repeated tension on the fascia can cause irritation and inflammation.
Since the fascia is connected to so many parts of your foot and leg, there are many things that can contribute to plantar fasciitis. “Poor running mechanics, flat feet, weakness of the hips, weakness of the core, poor control of pelvic positioning, and nerve irritation in the lower back,” can all contribute to this inflammation and pain, Licameli says. Tight calf muscles or even inflexible toes can strain this connective tissue, too, adds Ferber.
How to fix it: “We say to stretch and do heel raises to make sure the muscles crossing underneath the foot are good and strong. That takes the load off the plantar fascia,” Ferber says. “Plus, a good arch support (just an over-the-counter orthotic) will take some stress off.” Licameli also suggests strengthening the hips and the core (try this core workout for runners). “And always warm up properly,” he says.
4. Achilles tentonitis
What it is: This type of tendon injury causes inflammation and pain in the Achilles tendon, “especially when walking, running, raising up on toes, and stretching the calf muscles,” Licameli says. It’s an aching, dull pain, “usually right where the muscle transitions to tendon,” Ferber says. The pain can also be deeper in the thickest part of your tendon, which is more common as you age. Why? “As you age, you lose blood supply in the mid part of the Achilles tendon and it becomes brittle. It starts happening in about your 40s,” Ferber explains.
What causes it: Any weakness or tightness in the calves, glutes, or hamstrings can impact the Achilles tendon. We use our calf muscles and glutes to propel us forward, and if they’re not their doing jobs, smaller things like tendons have to kind of take over, which can end up causing a lot of strain. Licameli adds that having weak hips or core or flat feet can all impact how much strain is on the Achilles tendon.
How to fix it: Again, strengthening and stretching the muscles at play is key here. Often it’s the hips or calves that need to be strengthened, but issues with the feet are core are common, too. Ferber adds that since there can be so many different causes, you need to figure out the main one in order to properly treat it—that’s why it’s so important to see a professional to help you get to the bottom of it.
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Your joints need just as much loving as those hard-working runner muscles.
When runners work to prevent injury, it is often the muscles we think first to protect, stretch and roll out at the end of a long day out on the roads or trails. Though we should always focus on being proactive and protecting our hard-working muscles, there is another part of the body that we may not be focused on enough: our joints.
There are 143 joints in the human body that connect our bones together, and the Center for Disease Control (CDC) reports that more than one-third of Americans are suffering from joint discomfort. So how can we protect our joints before they start to cause pain?
Dr. James Rippe, world-renowned cardiologist, founder of The Rippe Lifestyle Institute, author of The Joint Health Prescription and editor of the American Journal of Lifestyle Medicine, explains that we are putting stress on our joints daily—and not just while exercising.
Related: Is Running Really Bad For Your Knees?
“Joint pain is one of the leading causes of disability in the United States,” he says. “We put stress on our joints by carrying extra weight, practicing poor posture and sitting improperly. In addition, many who keep active lifestyles and fitness routines are not properly attending to injuries when they occur, and therefore, set themselves up for long-term discomfort later in life.”
Dr. Rippe shares that in women, the leading cause of joint discomfort is being overweight or obese. He recommends you start really thinking about joint health as early as your thirties to help strengthen and lubricate joints and support them through aging.
One way to support joint health is through getting enough glucosamine, a natural compound in the body that supports the fluid found around joints. “What I’ve found in my more than forty years of practicing medicine and helping patients commit to fitness regimens, is that people do not get enough ingredients, like glucosamine, in their natural diets to help support joint health,” explains Dr. Rippe. “By incorporating a balance of healthy food in our diet and taking daily supplements, such as Osteo Bi-Flex®, which provides nourishing ingredients like glucosamine and chondroitin, we are helping to strengthen and support our joints as they gradually deteriorate with age.”
Related: Tackling Inflammation The Natural Way
In addition to supplements and diet, runners can promote healthy joints through their shoe choices, by finding a type that works best for them and their needs. There is not one shoe right for everyone, but Dr. Rippe suggests stability shoes with a cushioned midsole and heel or heavy, cushioned shoes while training, saving lightweight shoes for racing. “I also recommend those that have joint discomfort, to stretch regularly and to walk around the house barefoot,” he says. “Multiple studies have shown that being active while barefoot can provide a stronger platform for muscles to absorb shock and better support joints.”
Each volunteer completed both a sitting and running session on separate days.
Then the researchers looked for a variety of substances in the young people’s blood and synovial fluid.
In particular, they focused on molecules that are associated with inflammation. Low-grade inflammation in the knee has been shown to contribute to the development and progression of arthritis.
So the researchers looked for changes in the levels of several types of cells that are known to either increase or blunt the amount of inflammation inside the knee.
They also looked at changes in the levels of another substance unpoetically known as cartilage oligomeric matrix protein, or COMP. This substance tends to accumulate in diseased knees and is often used as a marker of incipient or worsening arthritis. People with arthritis can have about five times as much COMP in their synovial fluid as do people with healthy knees.
Unfortunately, because it had turned out to be technically difficult to safely extract much synovial fluid from these healthy knees, the scientists wound up with complete numbers from only six of the runners.
But the data were interesting and consistent. In almost every case, the runners’ knees showed substantially lower levels of two types of cells that can contribute to inflammation within the synovial fluid, compared to their baseline levels.
The runners also showed a shift in their COMP levels. After the run, they displayed more of the substance in their blood and less in their synovial fluid. In effect, running seemed to have squeezed the molecules out of the knee and into the blood.
Is Running Good or Bad for Your Knees?
Running has a reputation for causing wear and tear on knees over time, leading to joint pain, arthritis or other injuries. But a recent small study found that 30 minutes of running actually lowered inflammation in runners’ knee joints, leading many to question whether running really does increase a person’s risk for injuries—or if it helps prevent them.
In the report, published in the European Journal of Applied Physiology, researchers at Brigham Young University brought 15 healthy runners ages 18 to 35 into a lab where they took samples of their blood and knee joint fluid before and after they ran for 30 minutes on a treadmill. They also assessed the same samples when they were sedentary.
The researchers expected to find an increase in molecules that spur inflammation in people’s knee fluid after they ran, but they didn’t. Instead, they found that pro-inflammatory markers actually decreased after a 30-minute run. The scientists ended up only getting complete information from six of the people in the study, but they saw the same results in all of those people.
“It was surprising,” says study author Matt Seeley, an associate professor of exercise science at BYU. “We expected the molecules to increase, but it was the opposite.” Seeley stresses that the report is a pilot study, and that due to the small number of people, there’s not a lot that can be inferred from the findings. The researchers also only looked at inflammation right after people ran, rather than a week or month later. But Seeley says his team plans to do the same study in more people in the future.
“I think, and hope, the data shows that running is good for your joints,” Seeley adds. “Although the results are limited, they are also unexpected and could be important.”
Some experts not involved in the study say that while the study findings are intriguing—even given the small sample size—it’s not yet clear whether running can protect knees from injuries or arthritis. “There is data on both sides of the fence,” says Dr. Brian Feeley, an orthopedic surgeon at the University of California, San Francisco. “We know that there are some people that run all the time with no knee problems, and others that have arthritis at a relatively young age.” (Feeley was not involved in the recent study.)
For many runners, a 30-minute session is relatively short, and Feeley says the study does not necessarily suggest that long-distance running is safe. Other studies of marathon runners have found changes in cartilage that could suggest potential for injuries that can persist for months after a long race.
“Taken together, this suggests that there is probably an evolutionary advantage to allow us to run relatively short distances where our bodies protect cartilage from damage by decreasing inflammation,” says Feeley. “Long distance running may result in a situation where overwhelming the knee’s ability to decrease inflammation occurs, leading to the potential for joint degeneration.”
Both Seeley and Feeley agree that the benefits of running outweigh the risks of not running (especially if done in moderation.) Other factors, like weight or genetics, may also contribute to whether a person is more likely to get arthritis or other injuries from running. More research is needed to fully understand the risks and benefits. In the meantime, people who run can reduce their risk of knee problems through cross training and taking time to recover, as well as paying attention to any pain or swelling.
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Running May Be Good for Your Knees and Hips, and Marathons Aren’t Necessary
Ty Allison/Getty Images
If you love regular fun runs, then this news is for you. Moderate levels of recreational running may be the sweet spot for healthy knees and hips, according to a new scientific review in the Journal of Orthpaedic & Sports Physical Therapy. Compared with people who ran competitively or not at all, middle-of-the-pack athletes had lower rates of osteoarthritis over time.
The meta-analysis, which combined data from 17 previous studies involving a total of 114,829 people, also concluded that running at a casual level for up to 15 years—and possibly longer—is safe for healthy individuals.
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Overall, the international team of researchers found that only 3.5% of recreational runners developed hip or knee arthritis over the periods they were monitored for their studies. This was true for both male and female runners who reported running in amateur, non-professional contexts.
People who reported not running at all had a 10.2% chance of developing hip or knee arthritis. Meanwhile, those who were classified as elite or professional runners, or who competed internationally, had a 13.3% chance.
Research on running and joint health has, not surprisingly, delivered mixed results. But many studies have suggested some protective effects. A 2016 report from Brigham Young University, for example, found that running for 30 minutes reduced inflammatory markers around the knee joint.
The new meta-analysis didn’t group runners by mileage or intensity, because the definitions for recreational versus competitive varied between studies and were not always quantified with these measures. But in other research, they note, logging more than 57 miles per week has been linked to an increased risk of arthritis in these same joints.
RELATED: 7 Running Injuries and How to Avoid Them
The findings are good news for the majority of runners, say the authors. “Running at a recreational level can be safely recommended as a general health exercise, with the evidence suggesting that it has benefits for hip and knee joint health,” the wrote. That evidence is particularly strong in people who have run for 15 years or less, they say; there weren’t enough relevant studies to determine safety or joint-health benefits for people who had run for longer periods.
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The authors also could not determine the amount of running that is safe for weight-bearing joints, and they warn that their findings should be “interpreted with caution” due to limitations in the research, such as an inability to factor in potential factors such as obesity or prior injury.
Despite these limitations, the authors say their investigation provides valuable information for doctors, physical therapists, and other health professionals who might prescribe running to patients for athletic training or for general health. Plus, they wrote, the findings are also “of general health interest, given the high popularity of running worldwide.”
Is Running Bad For Your Joints?
You’ve probably heard it before. “Running is bad for your joints”. “It will wreck your knees”. “You’ll need a knee replacement in 20 years”. Most of these comments usually come from non-runners. Running is a natural action for humans, yet many people who don’t do it seem convinced that this highly beneficial exercise choice that burns many calories, improves heart health and reduces disease risk is bad for you. So could it be harmful to joint health?
It’s good news. A 20-year study conducted by Professor James Fries of Stanford University in California found that runners from the study (now in their 70s) revealed that those who run consistently could expect to have less arthritis than non-runners when they get older. It also showed that runners have a lower risk of osteoarthritis and hip replacements.
A 2014 study conducted by Dr Grace Hsiao-Wei Lo, Assistant Professor of Medicine at Baylor College of Medicine, found that running at any stage of life doesn’t increase a person’s risk of osteoarthritis of the knee. In fact, it may even help to ward off the condition.
The findings of the study, presented at the American College of Rheumatology Annual Meeting in Boston, looked at over 2,600 participants, giving them knee x-rays, assessments and surveys. Researchers concluded that runners had a lower prevalence of knee pain than non-runners, regardless of their age.
Born to run
The experts are not surprised. “Our bodies are designed to run,” says Professor John Brewer, Head of its School of Sport, Health and Applied Science (SHAS) at St Mary’s University (stmarys.ac.uk). “In the past we had to run to catch food or avoid being the food of a predator, so running is a natural form of human locomotion.”
Samantha Moss is Lead Physiotherapist for Nuffield Health (nuffieldhealth.com), and has been monitoring various studies. “There is currently no good evidence that running alone causes osteoarthritis,” she says. “There is some evidence that extreme levels of running, that those who run marathons and ultra marathons have a higher incidence of osteoarthritis, but there have been no good research trials into this to confirm a link either way.”
Moss adds: “A review of running and risk to joint health (published on the website PubMed.gov in the US) found no evidence that moderate levels of running in itself was detrimental. In fact, we can reduce the risk of osteoarthritis by maintaining a healthy weight, building muscle, flexibility and balance, which can all be achieved through activities such as running.”
Better bone health
Some loading of the joints is actually good for us. “Running can improve our joint and bone health, especially if we manage the volume and frequency of our runs,” says physiotherapist Stuart Mailer from Kensington Physio & Sports Medicine (kenphysio.com). “When we run, there is a high stress and load going through our joints and bone tissue that can improve bone density, helping to prevent osteoporosis and osteoarthritis. The bone remodels itself frequently and adapts to the stress it is put through. Running can help our joint health so long as we are sensible with regards to volume and intensity.”
So why does it hurt?
If your running technique is poor, you have weak muscles or imbalances, the wrong shoes or you overdo your running volume, you may suffer. “Problems can arise when an individual has a biomechanical issue that puts extra stress on a particular joint or when they do too much and refuse to listen to signals (like pain) telling them to rest or ease off,” says Brewer.
Unfortunately, carrying extra weight can exacerbate the problem. “Simple physics says that the greater the force through the joint surface, the greater the wear and tear, which is the essence of osteoarthritis,” says physiotherapist Mark Buckingham from Witty Pask & Buckingham (wpbphysio.co.uk). “The joint surface does not increase in size with an increase in weight, so therefore there is greater force on the same surface area. Hyaline cartilage is remarkable stuff but it can tolerate only so much and once it has gone, it’s gone – much like your teeth!”
“When each foot hits the ground with each stride, a force equivalent to three times a runner’s body weight is transmitted through the legs and lower limbs,” says Brewer. “When a runner is overweight, this is going to greatly increase forces and stresses transmitted into and through the knee joint, increasing wear and tear and the risk of problems.”
Experts advise trying to lose weight if you are significantly overweight as it can increase injury risk in general. “Being overweight or having previous injuries are some of the risk factors for developing osteoarthritis in the knees, hips and lower back,” says Moss. “Studies since the 1980s have demonstrated this risk factor repeatedly. However, being active and losing weight removes load through the joints and so reduces risk.”
If you are excessively overweight, you may choose to lose some weight first by sticking to low-impact exercise, such as cycling, swimming or using the cross-trainer. However, don’t be put off entirely. “Being slightly overweight and running 15-20 miles a week is likely to create fewer problems than being 10 kilos overweight and running 70 miles a week,” says Brewer. He also points out that if you take up running for the first time and you are overweight, you’re not likely to be doing long distances, which offers some protection from injury risk. “When someone who is significantly overweight runs, they are unlikely to have a higher level of fitness that can sustain running for long, or at a high speed,” says Brewer. “Therefore the potential for joint damage is greatly reduced, and consequently people who are significantly overweight should be encouraged to run at a tolerable speed as a means of burning calories and aiding weight loss.”
Often the warnings about running ruining your knees come from older relatives, who assume that a family history of arthritis means you’re guaranteed to have problems. Is that really the case?
If a first-degree relative had a knee replacement early on, then you may be more predisposed to joint issues in future. “A family history of osteoarthritis is an indicator that you are more likely to suffer yourself,” says Buckingham. “There seems to be a variance in the quality of cartilage between us. Some have very resilient stuff, which seems to put up with anything. Others have poor cartilage, which wears more easily regardless of how much you stress it with impact.”
Moderation is key, but don’t be deterred. “Simply put, if you have decent cartilage and no family history, then you can get away with a lot more,” says Buckingham. “If you have osteoarthritis in the genes then you are likely to suffer, and sadly, if you run and stress the cartilage, then you are much more likely to suffer early on.”
However, working on leg strength, ensuring your shoes are the right ones for you and having regular rest-days in between running sessions will all help. “I would never say avoid it completely,” says Brewer. “I think if you have a family history of osteoarthritis then running in moderation is still possible, but seeking medical advice first from an expert is an important first step. Start slowly, increase gradually and clearly, if there is a family history, it makes total sense to be cautious.”
Running may be part of your weekly training schedule but you could combine it low impact exercise to give your joints a break. “That includes cycling or swimming, both of which place less stress on the joints,” says Brewer.
If you want to do a longer race like a marathon and you have a family history of knee problems, then don’t be put off. Be sensible, train well, work with a physiotherapist to strengthen the muscles around the knees and rest up in between runs. “As long as you are sensible, I think it’s highly unlikely that they will increase their risk of arthritis or knee ops,” says Brewer. “Most will be fit as a result of their regular exercise and will have maintained a low body fat percentage, and these are important enhancers of quality of life as we get holder. Many hundreds of thousands of people run marathons and ultras each year, and they are not all queuing up for knee replacements afterwards.”
Running: Can it damage your knee?
Runners often ask orthopedic surgeons involved in sports medicine if running is inherently bad for their knees. If you jog regularly or do some other exercise, you might have the same question. The concern makes sense. Repetitive impact over and over to your bones and joints would seem to have detrimental effects to the bones and articular cartilage of your knees over time. That repetitive impact could lead to arthritis of the knee down the road.
Can we really conclude that physical activity is harmful to the knee?
Running and bone spurs in the knee
It does appear that a relationship exists between physical activity like running and osteophytes, or what you may know as bone spurs. Essentially increased physical activity can increase the presence of these bones spurs in your knee. Bone spurs can cause pain with range of motion, since these are rough edges of bones in a joint.
Physical activity and knee joint space narrowing
One of the hallmarks of arthritis on x-rays is narrowing of the joint space, or the space between the bones. There does not appear to be a relationship between jogging and joint space narrowing. Running or engaging in regular physical activity does not seem to necessarily lead to narrowing of the joint space between the bones of the knee.
Jogging and cartilage damage in the knee
Physical activity actually may be helpful for increasing the volume of the articular cartilage in your knees. It also appears to be associated with fewer articular cartilage defects in your knees. These findings suggest that if you like to jog, can have both the overall health benefits of exercise and prevent arthritis in your knee.
The overwhelming benefits of physical activity
I believe that the benefits of physical activity, including cardiovascular health, weight loss, mental health, and much, much more outweigh any risks of long-term damage to your knees. Even if you do develop arthritis in your knee one day, orthopaedic surgeons can treat it. If you do potentially need a hip or knee replacement later in life, your improved overall physical, mental, and emotional health from regular physical activity could make recovery from those surgeries easier. Plus running and jogging can make you happier and improve your quality of life.
Caution – Talk to your doctor
While it increasingly appears that regular sports and exercise could actually be good for your knees, or at least not as bad for them, as orthopaedic surgeons we struggle to make far-reaching conclusions. There are many patient-specific variables such as your weight, any prior knee injuries or surgeries you have had and more that can affect your risk for arthritis and later knee surgery.
If you like to jog and you know you have cartilage damage in your knee, prior knee injuries, or a history of surgeries, you should consider seeing an orthopaedic surgeon. You can discuss whether running is potentially harmful for you. Even if you cannot run every day, you often can perform non-impact activities, such as cycling, swimming, using an elliptical trainer or lifting weights. These forms of exercise can be mixed in with 2 or 3 days of running to improve your health while still protecting your knee.
Is running bad for your knees?
Do running shoes affect your chance of suffering an injury?
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