Marathon Training with Knee Pain: My Plan of Attack

It's been a stressful few weeks since my knee pain began. I still can't run half a mile without horrible pain and the Hawaii marathon is less than two months away. What's worse: the marathon registration fee is non-refundable, my plain ticket is non-refundable and my Airbnb lodging reservation is only 50% refundable. I stand to loose a lot of money if I don't make this trip happen. Although a trip to
Hawaii always sounds nice, everything was planned around this marathon. The thought of going without being able to run is a bit agonizing.

Part of me wants to play it safe, throw in the towel and just look for a future marathon without any more worry. On the other hand, there's still time and I have nothing to lose by sticking with it... other than my sanity and more severe injuries, right? Here's the clincher: I don't think the worst case scenario is not running the marathon; I think the worst case scenario is giving up and wondering if I could have run the marathon.

So that's where I stand. I want to run and I'm not giving up yet. I've got a plan, but first let me lay out the scenario...

Here are all the (not so) gory details of the injury:

  • I feel pain in my lower outer knee, right leg only.
  • I can run a short distance, about half a mile now (up from .03 miles two weeks ago) before the pain starts.
  • It begins as a numbing sensation that quickly escalates into a consistent sharp pain, like running with a knife jabbed just below my kneecap.
  • The pain disappears completely when I stop running, if I don't run through it for too long. I don't feel it at all when I walk, bicycle, use an elliptical or even run in place. As soon as start running forward, however, it begins to flare up. If I run through the pain long enough, as I did initially, then it persists after I stop and I can feel it when I lift/bend my leg or walk up and down stairs.
Marathon Training with Knee Pain: My Plan of Attack

Here's the diagnosis, thus far:

I was originally convinced it was either runner's knee (PFPS) or IT band syndrome (ITBS). I originally ruled out ITBS because I thought that only caused pain on the upper outer knee, whereas mine was lower. This made me lean heavily toward PFPS, until I read some posts about ITBS from people who actually did feel it in their lower outer knee.

My miracle-working doc examined me yesterday and didn't think it was either of those issues. On the contrary, he said the pain seemed to focus on the joint where my lower leg bones, the tibia and fibula, meet just below my knee (proximal tibiofibular joint). For some reason, they may be grinding together harder than they should as I land. After doing some muscle-testing, he was surprised how tight my calf muscles wereespecially the soleus. He told me this is a difficult muscle to stretch since it is so deep, buried under other muscles, and could be the cause of the pain. He believed this fit in with where and how I felt pain, especially since the pain wasn't consistent and stopped completely when I was on an elliptical.

Marathon Training with Knee Pain: My Plan of Attack

The good news is that inflammation doesn't seem to be an issue since the pain comes and goes. If it was inflamed I would feel it constantly, like I did when I ran through it for 7 miles a couple weeks ago, and inflammation could mean no working out. Also good news: it doesn't appear to be a sprain or any torn ligaments, either. If it were, I would have to give up hope right now.

So what does that leave me with? Well, this is a high priority for me so I'm eager to do anything and everything that may help. Even if it seems far-fetched, as long as it doesn't make anything worse then I'll give it a try.

The Plan:

This is how I intend to overcome my knee pain and continue training to run a marathon on January 19.

1. Elliptical, Elliptical, Elliptical!
As I said in my last post, the elliptical machine is my new best friend. Thank god I was conned into getting that cheap gym membership offer that I haven't used in over a year. It's valid till April 2014 and I'm definitely getting my money's worth now. I know the elliptical isn't a perfect substitute for the motions of runningif it was then it would cause pain in my kneebut it's the closest I'm going to get. I'm following my training plan and doing the same mileage at the same pace on the elliptical as I would on the road, and I can do it 100% pain free. The elliptical is allowing me to keep my fitness level up while continuing to strengthen leg muscles and improve my cardio. I still take energy gels, snacks and water like I would at an aid station, too. It's not so pleasant "running" inside as opposed to the beautiful Oregon scenery on my regular route, but it is a lot warmer. I'm actually more comfortable running in the cold air as my body heats up, but I realize this is closer to the warm temps I'll be (hopefully) feeling in Hawaii. I also continue to incorporate cycling cross-training, which I can also do without any pain whatsoever. Every now and then I try stepping on the treadmill  to see if there's any improvement, but I stop the moment I feel the first twinge of pain. Sadly, it doesn't take long.

Marathon Training with Knee Pain: My Plan of Attack
I can only imagine this is what I must look like on an elliptical.
2. Self-Massage
The foam roller and lacrosse ball are my next best friends. As I said in a previous post, they're my favorite torture tools for massaging knots and loosening tight muscles. If my chiropractor is right then those knots in my calves could be the source of my pain, but I'm doing work over the whole leg as well. This includes a long daily routine on the roller going over my quads, hamstrings, glutes, IT band in addition to all the tight spots in my lower leg. Since the upper soleus is very difficult to stretch I'm also just digging in with my hands throughout the day, although the lacrosse ball seems to work well, too.

3. Stretch Like Gumby
Much like massage, regular stretching is also part of my routine to help loosen those muscles. Stretching is a little more delicate, though, since it can also lead to injury and make everything worse. There are a lot of theories on the proper way to stretch and I've long planned to write a post about them. For the time being, here's my normal practice: dynamic stretching, after a brief cardio warmup, often right before a workout. Then PNF or static stretching right after the workout (I was doing AIS stretching but I'm preferring PNF now... more on that in a future post).

Stretching is easy, right? View post on
4. Strengthening
I'm trying not to take on too much because the last thing I want to do is overtrain my leg muscles while I'm trying to recover from injury, but I have begun some basic strengthening exercises for my quads, hamstrings, glutes, hips and IT band. I've learned these muscles play an important role in overall knee health. Even though it now looks like they may not be the culprit in my injury I still don't want to rule them out. I'm not doing strengthening exercises every day, but a few days a week—often right after a workout when all my muscles are warm and loosey goosey. If it's not a workout day then I still go through the dynamic stretching warmup routine first.

5. KT (Kinesiology) Tape
People swear by this colorful elastic tape. I picked up a roll at a local sporting goods store and have tried a couple different patterns on my knee. I can't say I've noticed any difference, and I really don't understand how having tape on your skin is going to affect muscles and circulation, but it seems to work for some people. This falls into the category of "it's not hurting anything, so why not?" As a related option, I've tried patellar and IT band leg straps with no noticeable effect.

Marathon Training with Knee Pain: My Plan of Attack
My latest pattern, based on suggestions online. They converge on the pain.

6. Ice
Pretty standard: chill regularly.

7. Supplements
Like the tape, if popping a few pills each day may help without any negative side effects, then why not? The difference, of course, is that supplements have much more evidence supporting them. I've already been taking a few, mostly to boost my immune system to ward off illness, but now I've added more. Unfortunately, I think the effects of supplements are more long-term and probably won't be seen in the immediate future. Still, they won't hurt. This is what I'm on and why:
  • Fish Oil: Anti-inflammatory (I know I said inflammation doesn't seem to be a concern, but I still think it's a good cautionary measure)
  • Turmeric: Anti-inflammatory
  • Magnesium: Muscle Relaxer
  • Acidophilus: Because if your gut is healthy, your body is healthy
  • Apple Cider Vinegar: Ditto
  • Zinc: Immune Booster
  • Vitamin C: Immune Booster
  • Vitamin D: Because Oregon winters are really dark, and there seem to be more health benefits from D than I can mention.
Marathon Training with Knee Pain: My Plan of Attack

8. Diet
This hasn't changed much since I was already a conscientious eater, but I'm getting more strict about it. I'm not counting calories, but I do try to follow a couple guidelines. They're very simple: avoid sugar, dairy, gluten and trans fats. Eat lots of colorful vegetables. 'Nuff said.

9. Meditation
I've gone through phases of practicing meditation for mental/emotional health, but since relaxing muscles could solve my problem then I hope to reap physical benefits from it as well. I try to do a mindfulness meditation for at least 15 minutes before bed. It seems to help me sleep better, too, which brings me to the last point...

Marathon Training with Knee Pain: My Plan of Attack
Visualizing a Healthy Knee
10. Rest and Sleep
These can be the most challenging. I want to stay up late every night massaging, stretching and strengthening my knee, but I know that rest days are important. It really tests my patience, because I see how close the marathon is coming and the thought of sitting around thinking there must be something more I can do to fix my injury is excruciatingly painful. Still, I know that much of the work I'm doing wears down my muscles and they need time to rest to grow stronger and healthier. And yes, my body and brain need sleep, too.

So there you have it. If I'm not at work then these are the things that are absorbing my life right now. The days are going by fast and I keep telling myself to stay positive. It's a challenge, but if it gets me running in Hawaii then it will all be worth it.

Marathon Training with Knee Pain: My Plan of Attack

And if you have any more tips then please feel free to share!

Photo Credits: Copyright 123RF Stock Photo


  1. Hi there,
    I am in the exact same situation as you. I am in the middle of marathon training and just started having the same kind of pain as you describe. Right now I can't even just 0.3 miles, how am I ever supposed to run 26.2 miles with this! Has your pain improved at all with this new routine? I would be interested if so since I am trying to find a new workout routine to still make my marathon!

    1. Hi. Sorry to hear you're going through it, too. I know how frustrating it feels.

      I think my routine was helping, but if you read my later posts you'll see that I made everything worse by running through the pain on a long run (when I knew better) and making everything worse. I had to drop out of my marathon because I seriously messed up my hamstring.

      For what it's worth, I did feel my pain was getting better, and now I'm a strong proponent of strength training. I mentioned that a little bit in this post, but I've learned a lot from Eric Orton's book, The Cool Impossible. He contains a lot of great exercises for strengthening leg and core muscles, which I believe would have prevented the problem in the first place. I'll be writing more posts about that soon.

      Good luck!

  2. I have the exact same symptoms and have taken two weeks off from running but still feel pain when I go downstairs or bend at a 45 degree angle. My physical therapist said my left tibia shifted down due to running on the roads and he adjusted it but it didn't help the pain much. I am worried since I am supposed to be on scholarship for cross country in the fall but at this point don't know if it's possible. Any tips? And did you find out what the actual condition is called?

    1. Hi Rebecca. Sorry to hear about your injury. Unfortunately, I never found the exact diagnosis for my injury, though it seemed to be either patellar tendonitis or just a simple case of ITBS (unusually low on the knee). If you follow my blog, you'll see that I did exactly what I shouldn't have done by running through the pain on a long 16-mile run and trying to change my gait to help it feel better. By doing so, I damaged my hamstring and took myself out of running for a good 7 months. I've only now finished PT and started running again at much shorter distances. That injury obviously trumped my original knee pain, but now that I'm running again it all seems to have healed and feels fine.

      In the end, I'm sorry to say that rest seems to have been the best answer, although it meant skipping my marathon in Hawaii (which was very tough to accept). I can tell you that after all my research and PT, I've come to believe that strength training is a very important part of injury prevention and treatment. The idea is that many injuries occur from imbalances in foot, leg and core muscles that lead to extra strain on particluar parts of your legs and knees. Doing targeting strength training exercises supposedly keeps everything strong and in balance to keep this from happening (it certainly seems to be a leading suggestion for dealing with ITBS and most knee problems). Jason Fitzgerald is a guru on the subject and has a website devoted to it: Also, Eric Orton's new book, The Cool Impossible, lists many strength training exercises you can do at home that I've found to be very useful. He's a notable coach for distance and ultra runners.

      The only other thing I would recommend is to keep looking for other opinions. I had a past ankle injury that a podiatrist told me would require months in an orthotic boot followed by an expensive regimen of physical therapy. I sought a second opinion from a chiropractor and he was able to fix the problem completely with one simple alignment session for $50 (and a second just to make sure it stayed fixed).

      I hope that helps. Good luck in your recovery. And remember that while taking some time off is tough, especially with a scholarship looming over you, it's better than getting injured and being unable to run for a year.

  3. Hi Martin,

    Thank you for posting your knee pain experience. I'm in the similar situation. My knee pain started couple months ago at the outer lower knee, right at the joint. It feels like a bruise. It's not too bad yet, but I can feel the presence and it starting to get a bit worse. But I was still able to run 11 miles 2 weeks ago, 7 miles last week. My NY Marathon is in 11 weeks. I don't want it to get worse, but not quite sure what to do. I read your blog. I've been doing these:
    - Diligently doing the stretching after each run
    - Twice a week bootcamp cross-training to strenghten my quads and core.
    - Taking joint supplement
    - Icing my knee (only once/twice a week though)
    - Foam rolling after each long run
    - Got new cushiony shoes
    - Wearing IT Band strap (occassionally)

    The next thing to try is KT Tape and taking Advil/Motrin. Should I contact my doctor and ask for a referral to sport injury specialist? I just don't want to hear them saying I should stop running.

    Any advice is appreciated. Thank you.


    1. Hi Jane. So sorry to hear about your pain! I know how frustrating it can be, especially with a big race on the horizon.

      Based on what I learned from my experiences, the best advice I can tell you is to listen to your body and don't push through the pain. In other words, REST! I know that's not what any runner wants to hear, but if you read my later posts you'll see that I decided to run through my pain on a 16-mile run because I didn't want to fall behind my training plan. The result was a much worse injury that knocked me out of my Hawaiian marathon and out of running altogether for several months. In the end, I believe taking the break is what finally healed me. In retrospect, if I let myself skip a few training runs that I considered "essential" when I finally started seeing improvement then I may have been able to run the marathon after all. If you're in the same situation as me, then maybe you've caught it early enough that taking a little time off will still get you back in time for your race.

      I still believe stretching, foam rolling and strength training are all very good for injury prevention and treatment, but be careful not to overdo it, which I also did. I learned from my PT that I was stretching too vigorously, which doesn't help flexibility and can lead to more injury. And strength training definitely needs adequate rest periods to be effective. Somebody explained it to me like this: you fuel muscles when you eat, you break down muscles when you work out and you build muscles when you rest. Also, my doc told me icing will only be effective if there is inflammation, which is usually identified by pain that lingers after you're done running... although it certainly doesn't hurt. He also said icing is also only effective if done at least 3x daily (about 15-20 minutes each time).

      Keep in mind that I'm not a doctor so anything I say should be taken with a grain of salt. Seeing a sports injury specialist was something I never did until after I missed the race and I feel he helped me recover very well. Of course, they'll always err on the side of caution so there's a chance you'll hear that you should stop running even if everything is looking better. You can also go my route of trying chiropractors or acupuncturists, which sometimes lead to quick miracle cures (they've cured my past injuries very quickly, but not the one described in this post).

      I hope that helps. Let me know how things develop!

      Good luck,

  4. Hi Martin,

    Thank you for your very sound advice. It is hard to accept the fact that I have to rest! You know exactly how I feel cos you've been there too. NYCM is only 10 weeks away :(. But you are absolutely right. I don't want it to get worse and end up not being able to do the race at all, that's even worse. Maybe I should take 2 weeks off now and continue with 8 weeks training until race day.

    I made appointment with my doc this coming Wed. Let's see how it goes. I'll keep you posted :)


  5. Thank you for sharing. I agree with you. This is not a bone issue. It is muscle. I usually lift but i like to run on Sundays. Yesterday I did 9 miles and for the second week it hurt quite bad. I will rest now because this time its worst than last week. Back to squats, stiff legged dead lifts, dead lifts, and hack squats. I think i will beat this with strength training and in a couple of weeks, I will start interval training with sprints.

  6. Good luck Kun! I hope your recovery goes well!