Thirty five-year-old Smitha Pendharkar used to play tennis and then took to running to keep fit. But, one day in 2012, she when she tripped and fell while running on a concrete track in Versova in west Mumbai. Since then she has struggled with osteoarthritis in her knees, a condition in which the cartilage cushioning the knee bones gets eroded with a build-up of fluid a in the joint.

At 40, Anthony Soares suddenly realised that he was unhealthy and needed to get fit. So he got himself a wearable fitness tracker and started running to lose weight till he started experiencing excruciating pain in his knees. When he went for a check-up he was told that his left foot did not have an arch – a condition called being flat footed. Arches of the foot are formed by the tarsal and metatarsal bones and supported by ligaments and tendons. The structure allows the foot to take the weight of the body and acts as a shock absorber acts as a shock absorber during locomotion. Soares’ right foot did have an arch and his mismatch distributed his body weught unevenly between his feet. Putting his left knee under pressure from suddenly running caused an overporduction of synovial fluid in the joint making it swell and the ligament to tear.

Niti Nirvan, 27, who has been playing football for the last 10 years twisted his knee during the game in 2014. He continued playing and was irregular with the physiotherapy his doctors had advised. In August this year, he hurt his knee again in an impact injury during a game. He found himself unable to bend his knees and was advised bed rest for a few days.

“I have been having knee issues on and off,” said Nirvan, who started walking again only after a couple of weeks of physiotherapy. “But this time around it’s serious and I have been asked to stop playing football. I am hoping it’s only for a while and I will be able to play soon.”

Niti Nirvan, who has had two serious knee injuries while playing football. (Photo: Niti Nirvan)

In the last decade or so, fitness has become in vogue, with people taking to running marathons, ultra marathons, trail running, cycling, trekking and high altitude trekking. But many fitness seekers are not aware of the stresses they could put their bodies through. For instance, how many people actually get a full body assessment before they start an extreme activity? While running, for example, how many people, ignore niggles to their knees until it is too late and injury leaves them immobile?

“The golden rule is to learn to listen to their body,” said Dr Anjana Laungani, physiotherapist at Physio Rehab in Mumbai. “The myth that most people have is ‘no pain no gain’. This is something that people should not follow”.

Laungani has had patients who attribute the pain they experience to simply resuming exercise after long periods of time. She finds that many do not think to address the pain even for peiods as long as six months.

Laungani says that if an individual’s body is ready for a new activity – running, trekking or any other sport – they should have no pain at all. There can be some soreness of the muscles but that should settle within a few hours. The new activity should not leave them with a throbbing pain or a pain that keeps them awake all night or a pain that makes them limp.

Runner's knee

“For the longest time I have been hearing how bad running is for the knees and how it leads to arthritis of the knee,” said Chauhan, talking about the popular percenption about knee injuries. “These kinds of statements come from sedentary doctors and non-runners. It’s disappointing because there is no scientific evidence to support them.”

Chauhan himself has been running for 30 years and is the founder of the La Ultra runs of 111km, 222km, and 333km in the Leh-Ladakh region. “I am of the opinion that running, whether on hard or soft surfaces, is not bad for the knees,” said Chauhan.

A study published in 2013 in the journal Medicine and Science in Sports and Exercise analysed data on more than 74,000 runners compared to 15,000 walkers and found that runners who did not already have knee arthritis, had a somewhat lower risk of hip and knee osteoarthritis as compared to people who only walked. This benefit was partly due to runners’ lower body mass index and held true even of marathoners.

Another study in the same journal measured the forces on knee joints of people while they were running and walking, based on the premise that the knees bear greater peak contact forces while running. The results showed that these peak contact forces were blunted by the relatively short ground contact time and long strides taken by a person while running as opposed to walking and the loads on the knees while running and walking were not very different.

The susceptible knee

The knee is one of the most complex joints in the human body that joins the thigh bone called the femur to two bones in the shin. The knee itself has a number of knee bones, a knee cap, ligaments that hold the knee bones together and tendons that join the bones to muscles in the leg.

The knee is also the joint most prone to injury, Laungani explains. Being the crucial hinge between the foot and the hip and the back, the knee absorbs stresses that might arise from dysfunction in these parts of the body.

Left knee-joint from behind, showing interior ligaments. (Image: Wikipedia/Anatomy of the Human Body - Henry Gray/Henry Vandyke Carter)

“I call it the middle child syndrome,” said Laungani. “You know how in the family we have an elder child, a younger child and a middle child gets really whacked around by them and bullied. The knee is treated in exactly that way.”

According to her, the physician who examines a knee injury should also look at the patient’s foot, hip and back along with the knee. In most sports, people walking, running or climbing using all these four parts of the body called the “lower quadrant”, intensely. To be effective, the four have to work in synchrony.

Faulty foot alignment is one of the most common causes of knee injuries. A flat-footed person is more prone to injury. Weak muscles in the hip, weak gluteals in the buttocks, and weak core muscles can also trigger trauma in the knees. “If an individual does not have very good core muscles that give him the power to run, then all he would do is put all the weight of his body on his knee,” explained Laungani. Core muscles reside in the torso in the region of the stomach and mid- and lower back.

Troubles in the knees can also be triggered by Vitamin D deficiency, often due to lack of exposure to sun. “Vitamin D deficiency also leads to calcium deficiency and today you find lots of younger people coming up with orthopaedic issues such as knee problems,” says Sharmila Sinha, a physiotherapist in Navi Mumbai.

Laungani says that only 20 percent of the knee injuries she sees are due to weak musculature in the knees. The rest are indirect problems that have led to overloading of the knees.

Apart from weakness in the lower quadrant, poor running form can alo be injurious to knees. “Most of us have tightened or shortened hamstring and iliopsoas muscles as a result of sitting all the time,” said Dr Rajat Chauhan, physician of sports and exercise medicine and musculoskeletal medicine at Ashoka University in Sonepat.

Posterior view of right leg showing the hamstring muscle. (Image: Wikipedia/Medical gallery of Mikael Häggström 2014)

The hamstring is one of the three posterior thigh muscles. Iliopsoas muscles consist of the iliacus muscles, which span from each groin to the sides of the pelvic cavity. These muscles are large and long.

“When these muscles, which are prime movers when you run, can’t perform their task with efficiency, the knee joint is put under unnecessary stress,” added Chauhan. He said that with these muscle imbalances it is not so much a question of whether an injury occurs as when it will occur.

Getting ahead of injury

“I have had some really sensible come people coming to me who tell me, ‘I am 40 and now, I have time for myself so I want to run the marathon or take up a sport. But, before I do that I want to be sure that my body is fit to take the stress’,” said Laungani. She further adds that a lot depends on at what age one starts a new activity. A 40-year-old should first seek professional help before and check for all risk factors before starting an exercise routine.

A physiotherapist can perform a lower limb kinetic chain assessment – a series of movement tests for the feet, hip muscles and core muscles. And, as with most things, it is easier to get the assessment first and prevent injury and to fix one, said Laungani.

“To become a better runner and stay injury-free, it’s important to correct muscular imbalances first by sticking to a regular programme of strengthening and conditioning exercises,” reiterated Chauhan.

These are lessons Pendharkar and Soares have learnt the hard way. Soares has now acquired orthopaedic soles that help to create an artificial arch for his flat foot and ease pressure on his knee while running but even those will have to wait. Physiotherapist Sinha said that arch insoles are essential for people with flat feet but also recommends flat feet exercises to tone muscles in the foot and correcting walking postures to ease the pressure on knees and feet.

“Due to the knee injury, I have stopped running for now. I cannot until my knee is healed,” Soares said.

Pendharkar has come to depend on medicines to manage her pain for the last four years. She also takes calcium supplements to strengthen her bones, vitamin supplements like D3 to encourage calcium absorption, B12 and folic acid to increase the formation of healthy red blood cells in her body.

The pain in her knees keeps Pendharkar away from outdoor exertions except very light exercise. “I have stopped going for treks or indulge in other outdoor sporting activity,” she said.“I only go for walks.”