Runner’s Knee on the Trail: What Helps and How to Rebuild
Trail Notes | Strength, Injury & Recovery
when the descents start talking back
Runner’s Knee
on the Trail.
It often begins as a dull ache around the kneecap. The climb feels manageable. Then the descent makes it impossible to ignore.
Patellofemoral pain, commonly called runner’s knee, is pain around or behind the kneecap that is aggravated by activities such as running, squatting, stairs and prolonged sitting.
For trail runners, descending is often where it becomes most obvious. Each downhill step asks the quadriceps to control the body as the knee bends. Add fatigue, technical terrain and more descent than you have recently trained for, and the demand can rise quickly.
The good news is that patellofemoral pain can often be managed well. The plan is rarely one magic exercise. Current best practice combines education, appropriate load modification and progressive knee-focused exercise, with hip work and other supports added according to the individual.
Runner’s knee is not always caused by one weak muscle, one imperfect foot strike or one training mistake.
It is usually a load-and-capacity problem shaped by several factors. That is why assessment and an individual plan matter.
Trail Note · 01
What runner’s knee actually means
Patellofemoral pain describes symptoms around or behind the patella, rather than one single damaged structure. It is commonly aggravated when the knee is loaded in a bent position.
You may notice pain while descending, using stairs, squatting or standing after sitting for a long time. Some runners can keep moving once they warm up, while others find symptoms build as the run continues or appear afterwards.
The pain is real, but it does not necessarily mean the kneecap is rubbing incorrectly or that cartilage is being damaged. Patellar “tracking” is only one possible part of a much broader picture.
The knee is where you feel it. The plan should consider the knee, the hip, the running demand and the person attached to all three.
Trail Note · 02
Why it develops
Patellofemoral pain is usually influenced by more than one factor. A common pattern is that training demand increases faster than the runner’s current capacity to tolerate it.
Possible contributors
A recent increase in total running, speed, elevation or downhill exposure.
Insufficient knee or hip strength for the training currently being attempted.
Movement or running patterns that increase symptoms for that particular runner.
Reduced recovery because of illness, poor sleep, life stress or under-fuelling.
Previous pain, fear of loading the knee or a return to running before capacity has been rebuilt.
Foot posture, footwear and running form may matter for some people, but none provides a universal explanation. They should be considered when assessment shows they are relevant, not treated as automatic faults.
Trail Note · 03
Strengthen the knee and the hip
Exercise therapy is a central part of current best practice for patellofemoral pain. The strongest message is not that every runner needs endless glute activation. It is that the knee needs to become more capable of accepting load.
Knee-focused exercises can train the quadriceps and improve tolerance to loaded knee bending. Hip-focused exercises can support strength and control higher in the leg. Many runners benefit from a combination, but the starting point should reflect which movements are currently tolerable.
Someone who cannot yet tolerate a deep squat may begin with a smaller range or more hip-dominant work. Someone with good tolerance may progress directly into heavier knee-focused loading.
Knee capacity
Squats, split squats, leg press, knee extensions, wall sits and step-downs can all be useful when selected and progressed appropriately.
Hip capacity
Deadlifts, step-ups, hip thrusts, lateral work and single-leg exercises can build strength around the hip and support whole-leg control.
Trail capacity
Controlled lowering, single-leg work and eventually downhill running prepare the body for the braking and stability demands of descents.
Progressive demand
Range, resistance, repetitions and speed can be adjusted over time. The goal is increasing capacity, not collecting more corrective exercises.
Trail Note · 04
Treat descending as its own training load
Elevation gain gets most of the attention in trail training. Elevation loss deserves its own line in the plan.
Downhill running increases braking demand and requires the quadriceps to repeatedly control the knee while the body moves forward and down. This is useful training when introduced progressively. It can be an abrupt overload when added in one large dose.
Build descent exposure gradually across the training block. Consider the steepness, technical difficulty, speed and total time descending, not only the kilometres completed.
Her Trails coaching cue
Do not add more distance, more speed and substantially more descent in the same week. When a new stressor enters the plan, give your body enough space to show you how it responds.
Trail Note · 05
Running retraining can help selected runners
Some runners experience less knee pain when they slightly increase step rate and reduce overstriding. On descents, shorter steps can also reduce the feeling of braking heavily with each landing.
That does not mean every runner should force a particular cadence, foot strike or knee position. Running retraining works best when an assessment identifies a movement pattern connected to the runner’s symptoms and the change produces a useful response.
Poles may redistribute some loading on steep or technical terrain, but they are an optional tool rather than a treatment for patellofemoral pain. Strength and appropriate training exposure remain the foundation.
Trail Note · 06
What to do during a flare
The aim is to reduce the movements or training doses that are keeping the knee irritated while maintaining useful activity where possible.
Practical first steps
Temporarily reduce the distance, speed or descent that clearly aggravates symptoms.
Use flat running, walking or low-impact cross-training if those options are comfortable.
Continue tolerable knee and hip strengthening at an appropriate range and load.
Monitor whether symptoms settle back towards baseline by the following day.
Seek assessment if pain is worsening, persistent or affecting normal walking and daily life.
There is no universal percentage by which every runner should reduce training, and no single pain score that is safe for everyone. Your response and diagnosis should guide the plan.
Trail Note · 07
When knee pain needs assessment
Not all pain at the front of the knee is patellofemoral pain. Seek prompt assessment after a fall or twist, or if you have significant swelling, locking, instability, an inability to bear weight or pain that is severe or rapidly worsening.
Assessment is also worthwhile when symptoms are not improving after a reasonable period of load modification and consistent exercise. A physiotherapist can review the diagnosis, identify the most relevant contributors and tailor the progression.
You do not need perfect knees to run trails. You need a plan that builds enough capacity for the trails you want to run.
Strong knees are not built by avoiding every load. They are built by applying the right load, at the right time, with enough recovery to adapt.
Build the knee. Build the hip. Build the descent. Let each layer earn the next.
build the descent before race day
Written by the Her Trails coaching team
Trail Notes are evidence-informed coaching journals written for women who train, race and run on trails.
Key references
Neal BS et al. Best practice guide for patellofemoral pain. Br J Sports Med. 2024;58:1486–1495. PMID 39401870.
Willy RW et al. Patellofemoral Pain Clinical Practice Guideline. J Orthop Sports Phys Ther. 2019;49:CPG1–CPG95.
Daviaux Y et al. Effect of poles on foot–ground kinetics during trail running. Eur J Sport Sci. 2013;13:468–474.
Keep going with us
General education only, not medical advice. Persistent, severe or worsening knee pain should be assessed by a qualified health professional.
