Running With Pain: How to Modify Your Runs for Hip, Knee, Shin, and Foot Pain

Written by Natalie LaMendola, a DPT and RRCA & USATF Certified Running Coach for Running Explained for over 5 years.

Running is a tough ask on your body. It has numerous health benefits, sure, and we’ve learned over the years just how beneficial it can be for various health outcomes. But, despite all of those facts, it still is an incredibly high demand on your musculoskeletal system. Aside from basic running simply for the act of running, training for a specific race outcome means you’re pushing your body to, or oftentimes past, your previous limitations.

All that to say, it’s normal for you to “feel something” on your runs. Most of them, even. 

I’ve run for nearly 20 years, including competing collegiately and completing numerous marathons. I’m thirty years old. It’d be unusual for me to not feel any discomfort, even to a small degree, on my everyday runs. 

The good news? Discomfort, and even some mild to moderate pain, doesn’t mean you automatically are injured. Better yet, it doesn’t even mean you need to stop running. 

When we look at how most running injuries occur, it mostly comes down to 2 main things: tissue capacity, and distribution of load. Tissue capacity describes the ability of the various tissues in your musculoskeletal system (bones, muscles, ligaments, tendons, etc) to withstand the demands placed on them during an activity. Distribution of load describes how the forces generated in running (both from the ground and from your body) are dispersed throughout your lower body. 

A skilled running-specific physical therapist can assess and help you improve tissue capacity. But you, the runner, can assess and modify the distribution of load as it relates to your symptoms when something starts to not feel right. Here’s a guide on how to do that, based off of two things: the affected body part, and the main contributors of force distribution when on the run.

HIP PAIN

By far, the two biggest things that can majorly impact loading through the hip is incline and pace. No matter the source of pain, seeking out level ground and temporarily cutting out speedwork is often the first solution. When you have hip pain, here’s what to address (in order of importance):

• Incline - avoid running uphill

• Pace - slow it down; temporarily avoid speedwork

• Treadmill vs. overground - doesn’t matter

• Cadence - it really depends on the location of symptoms; increase in cadence offloads some sites

• Footstrike - doesn’t matter

• Shoes - doesn’t matter

KNEE PAIN

The knee is, unfortunately, affected by so many factors. All of the ones we’re addressing play a role in how much the knee is loaded. The upside to that, though, is that there’s a lot of opportunity to modify things and temporarily offload that site. When you have knee pain, here’s what to address (in order of importance):

• Incline - avoid running downhill

• Cadence - aim to increase by 5-10%

• Footstrike - midfoot or forefoot; avoid heelstrike if severe

• Pace - try to go ever so slightly faster

• Treadmill vs. overground - treadmill preferable

• Shoes - aim for lower heel drop option

SHIN PAIN

Similar to the knee, the shin (more specifically, the tibia) is affected quite a bit by all of the factors we’re discussing. There’s a hefty amount of research that demonstrates the tibia is more affected by muscular forces acting on it (namely, the calf musculature) than by environmental factors, but regardless, we do know that changing some things can help offload that bone. When you have shin pain, here’s what to address (in order of importance):

• Incline - avoid both uphill and downhill; stick to level ground

• Pace - slow it down; temporarily avoid speedwork 

• Treadmill vs. overground - stick with outdoors; avoid treadmill

• Cadence - a 5-10% increase MAY help, but that’s lower on the priority list

• Footstrike - depends on your symptom location; most tibia pain is posterior or posteromedial, in which case a forefoot strike should be avoided

• Shoes - aim for lower heel drop option

FOOT PAIN

The biggest factors affecting your foot pain have largely to do with the surfaces your foot in interacting with directly - the ground and the shoes you wear. Surface type is a lot more straightforward, but with shoe technology changing constantly, that factor is a bit more gray. When you have foot pain, here’s what to address (in order of importance):

• Pace - slow it down; temporarily avoid speedwork 

• Shoes - a higher heel drop can offload the foot more, but a rocker-style shoe may need to be avoided depending on symptom location and where in the shoe the rocker is positioned

• Treadmill vs. overground - stick with outdoors; avoid treadmill

• Incline - avoid both uphill and downhill; stick to level ground

• Footstrike - depends on your symptom location, but even then it’s only going to matter for very site-specific pain and very extreme footstrike types

• Cadence - doesn’t matter

WHEN IS PAIN OKAY TO RUN THROUGH?

Patients often get frustrated when I ask them to describe the nature of their pain, saying something like “I’m not very good at describing pain!” or “I hate this question, I never know what to say.” That’s a normal thing to feel, as pain is a very subjective and personal experience. There’s a dozen ways the same injury at the same site could be described by two different people. 

What we do know is that there are certain types of pain that, more often than not, are more concerning than others. If you feel like you can describe your pain in any of the following ways, and it is unchanging for more than a few days, then it’s time to reach out to a professional. 

-pain that is sharper in nature, versus dull/achy/sore

-pain that is localized to one smaller area, versus a more vague/broad location

-pain that worsens as you run, or continues to hurt when you are off the run later

-pain that starts to limit your functionality in daily activities outside of running

-pain that interrupts your sleep

-pain that radiates down your leg in any manner

-pain that is concerning to you

OKAY, SO I TRIED THE MODIFICATIONS LISTED ABOVE, BUT MY PAIN ISN’T GOING AWAY. WHAT NOW?

A running-related injury is defined in the PT world as one that forces you to modify your runs in any way for 3 consecutive outings. If you are having symptoms from the list above for this amount of time, then I’d reach out to your trusted local running-specific physical therapist. If you are having symptoms that are less severe or not on the list above, but they are still present and cause modifications for 3 consecutive outings, then I’d still reach out. 

At the end of the day, though, all these guidelines are exactly that - just guidelines. If your symptoms are concerning to you in any way, that’s reason enough to seek out help.

Not sure where to start? We can help you build a plan that works around a niggle instead of through it. 1:1 coaching or Kickstarter Call  |  Want to build tissue capacity for the long haul?

About the Author

Natalie is a running-specific Doctor of Physical Therapy and certified run coach based in Kansas City. When she's not working with runners at her practice , you can find her chasing her own goals on the run alongside her husband, twin toddlers, and hound dog. Her passion lies in helping runners of all abilities achieve their goals and get back to the miles they love. If you want to hear more listen to Natalie talk about Strength Training on this Episode of The Running Explained Podcast

References

Firminger CR, Edwards WB. The influence of minimalist footwear and stride length reduction on lower-extremity running mechanics and cumulative loading. J Sci Med Sport. 2016;19(12):975-979. doi:10.1016/j.jsams.2016.03.003

Goom TSH, Malliaras P, Reiman MP, Purdam CR. Proximal hamstring tendinopathy: clinical aspects of assessment and management. J Orthop Sports Phys Ther. 2016;46(6):483-493. doi:10.2519/jospt.2016.5986

Han S, Moon J, Lee J, Han S, Sterzing T, Farris D, Rice H. Influence of manipulating running foot strike angle on internal loading of the tibia. Scand J Med Sci Sports. 2025;35(5):e70066. doi:10.1111/sms.70066

Lu Z, Suo B, Deng L, Wang J, Fu W, Zhong Y, Jin J. A review of uphill and downhill running: biomechanics, physiology and modulating factors. Front Bioeng Biotechnol. 2025;13:1690023. doi:10.3389/fbioe.2025.1690023

Petersen J, Sørensen H, Nielsen RØ. Cumulative loads increase at the knee joint with slow-speed running compared to faster running: a biomechanical study. J Orthop Sports Phys Ther. 2015;45(4):316-322. doi:10.2519/jospt.2015.5469

Yamato TP, Saragiotto BT, Lopes AD. A consensus definition of running-related injury in recreational runners: a modified Delphi approach. J Orthop Sports Phys Ther. 2015;45(5):375-380. doi:10.2519/jospt.2015.5741