The basics of running knee biomechanics

During foot pronation, with the rearfoot fixed to the ground, your leg will usually follow the movement of your upper ankle. It means that the tibia - leg bone - being tightly locked with the talus - ankle bone -, we see a medial move of the ankle - adduction -, an internal rotation of the leg, knee flexion and adduction.
Movement is reversed during the propulsion phase of the gait.
Both happen with relative synchronicity.
Overall, the knee exhibits less motion than the tibia and the ankle.
If you pronate for too long, the system becomes asynchronous, and tibia internal rotation is prolonged. The joint that will compensate for this is the hip, in order to keep the ankle/knee/hip alignment. This results in some excessive loading of different structures, as well as excessive contact pressure on the kneecap.
As we will see later, a potential way to prevent this knee problem is to strengthen hip rotator muscles.
At this point, we already have seen that knee pain can either be caused by a foot issue - excessive pronation - or a hip issue - weak muscles.
In our next post, we will discuss knee strength.

Foot orthotics and running

Foot orthotics have been proven to help with the treatment of running-related musculoskeletal injuries. 70 to 80% of people with chronic knee injuries get substantial benefits from such items. 

While several studies have shown a good amount of help with pain control, we do not really understand why the orthotics help so much. The mechanism remains unclear. The biomechanical changes are relatively small, and help to control rearfoot eversion, but only to a small degree. It has been hypothesized that they help to reduce the strain on our plantar fascia or help to reduce the midfoot kinematics - remember that most people show hypermobility there.

Some studies also concluded that there are no significant benefits of heat-molded orthotics compared to the non-molded ones.

As for the shoe itself, you have to consider your foot type and the mechanics associated when choosing an orthotic. You may first test an affordable, over-the-counter model to see if it brings you measurable benefits. Then decide to go for the tailor-made option to get the most of this approach.

At Hong Kong Sports Clinic, we do believe that such devices are better used temporary, to help controlling symptoms - reducing pain. We focus more on finding what could actively help with foot mechanics - joint mobility, muscle strength, etc.

Stay tuned as we move up the kinematic chain and discuss knee mechanics next!

Footwear research findings

Research is conflictual when it comes down to the type of shoe you wear, and the associated injury-rate.

Despite this fact, it makes sense to pick up a shoe that matches your foot type. Flat feet? Try the motion control type. High arch? Go for the neutral type. You obviously do not want to “aggravate” an existing condition.

Some good quality studies have randomized one of the three shoe types with one of the three foot types. Inc conclusion, the authors found a very similar distribution of injuries among all different groups.

What does this mean? Basically, you want to go for a shoe that matches your foot structure - common sense - but also, and maybe even more importantly, that feels really comfortable. Do not focus on the price too much. Try it and decide immediately if it fits you well, or not.

Statistically, most people have an inward forefoot flare after landing and should be fitted for a semi-curved or curved shoe.

A final note about barefoot/minimalist shoes running: there is, to this day, no evidence for benefits towards injury prevention. Some studies even showed an increase in the injury rate. Running with these shoes usually mean a change in technique - forefoot strike - that decreases the loads on the hip, but increases the loads around several foot areas. You want to be very progressive and careful when transitioning from regular to minimalist shoes.

What are risk factors for a running overuse injury?

As for many injuries, it is hard to identify one unique factor that puts you at risk of an overuse injury.

Remember the 4 main causes of pain with running? Let’s discuss each one.

Atypical foot mechanics: conflictual evidence exists.  To this day, it would make sense but we cannot be sure that hyper-pronation, in isolation, puts you more at risk of getting injured.

Strength: when the foot pronates, the ankle unlocks and more muscle work is required to maintain stability. The tibialis posterior, if weak, will affect the control of the ankle joint movement. It also helps to support the arch of the foot. Therefore, a weaker tibialis posterior diminishes ankle stability and forces other muscles - like the soleus, part of your calf group - to work more, causing Achilles tendinopathy and/or overall calf tightness. It also adds stress to the plantar fascia, increasing the odds of plantar fasciitis development.

Anatomical alignment: because of the difference between static - or structural -  alignment and dynamic - or functional - alignment, no study could clarify the real impact of flat/arched feet on the incidence of overuse injuries. Too many compensations may occur, especially from muscles, to exactly understand what may happen.

Flexibility: first ray hypomobility seems to be associated with increased rearfoot eversion. Reduced calf flexibility - or increased tightness- seems to be associated with increased energy absorption at the ankle during the first half of the stance. Which means more stress at the ankle.

In conclusion: with only one variable outside of its normal limits, it is unlikely to expect abnormal pronation patterns. But if you combine weak muscles, hypomobile joints, and flat feet, it can start to increase the load on various anatomical structures. And eventually leads to an injury.

Foot mechanics #2

During the first half of the stance, the midfoot and the forefoot do the majority of the work, in comparison to the rearfoot. 

The natural movement associated with the rearfoot eversion is a combination of vertical and medial midfoot displacement.

This means that a tight arch will have you compensate with the rearfoot. The arch undergoes significant deformation for about 75% of the whole stance phase. A genuine good reason to work on the mobility and flexibility of your foot!

In order to make it up for the fixed heel bone in contact with the ground, the tibia has to rotate internally and the knee goes into flexion.

While pronation is normal for most runners, prolonged pronation may increase the risk of injury.  If pronation continues after the midstance, a mechanical dilemma occurs at the knee joint. The tibia wants to externally rotate and the knee wants to extend, but because the foot has achieved more internal rotation than necessary, the hip starts to excessively rotate in order to keep good joint alignment at the knee. 

Excessive contact pressure on the kneecap may then occur and put the runner at risk of cartilage deterioration and anterior knee pain.

Foot mechanics #1

Starting to talk about the foot makes perfect sense.

It all starts from here. Every time you land on the foot, the ground reaction force initiates there and moves up the kinematic chain.

The first half of running gait is referred to as an eccentric or cushioning phase, while the second half is referred to as a concentric or propulsion phase.

At impact, the foot is supinated - the outside part of it absorbs most of the initial shock. The foot is safe in a locked position. Just before midstance, the foot pronates and unlocks. Then, as the heel lifts off the ground to prepare for the toe-off, the foot supinates again, allowing the forefoot to become a rigid propulsor, helping the runner to move forward.

Pronation happens during the first half of the stance until the heel lifts off the ground. It combines ankle dorsiflexion, rearfoot version, and forefoot abduction.

Foot pronation is a necessary protective mechanism. It absorbs, adapts, and prepares. It allows impact forces to be diminished over time, helps the foot to handle uneven ground surfaces, and prepares for the propulsion phase by increasing the contact of the first ray of bones with the ground.

The 4 main factors causing you pain while running

A large amount of speculation exists regarding the mechanisms of running injuries. Even though there is conflictual evidence in regard to the risk factors, some studies have provided good insights about what can cause runners to get injured.

The four important factors are as follow: biomechanical gait patterns, muscular strength, anatomical alignment, and tissue flexibility.

Given the complexity of running injuries, it is important to develop a systematic approach to the gait assessment.

It is also easy to understand how our daily life activity - or, for many of us with deskbound jobs, inactivity - can contribute to the puzzle. Sit too much and your hip muscles get shutdown. Wear tight shoes, with too much cushioning, and your feet become rigid and stiff.

In our next post, we will start with our first contact with the environment:  the foot. Assessing foot mechanics is an important part of figuring out why you may have knee, hip, or even lower back pain. 

The second most common knee pain for runners

Iliotibial band syndrome

Iliotibial band syndrome or ITBS is the second most common knee pain with runners and the most common one on the lateral side of the knee.

It has been suggested that the frictional forces between the ITB and the lateral femoral condyle/bone are the highest at 20-30 degrees of knee flexion. This happens during the first half of the stance phase of running.

Key facts of ITBS

To this day, we haven’t found any biomechanical difference in flexion/extension patterns with runners suffering from ITBS and pain-free runners.

The supposed role of the band is to stabilize the knee, resisting to hip adduction and knee internal rotation. Abnormal foot and/or hip mechanics can come into play. 

At this point, we consider that one or a combination of the following can be at the root of causing ITBS: pelvic drop - from weaker hip abductor muscles - and atypical anatomical alignment - from excessive knee internal rotation, resulting in a knee collapse.

To sum it up

To help with solving a knee problem, we have to carefully look at your foot and your hip joints and muscles. In many cases of overuse injuries, a knee problem resonates with other upstream or downstream problems.

The first and most common knee pain for runners

Patellofemoral pain syndrome


Patellofemoral pain syndrome or PFPS is one of the most common injuries in running and jumping. It accounts for half to two-thirds of running-related knee pain.

Despite being so common, its cause remains vague and discussed. The onset is often insidious, located around the kneecap. No specific cause has been constantly reported, other than overuse.

Key facts of PFPS

Women are twice as likely to sustain PFPS compared to men. A potential cause is that women may show increased hip internal rotation, leading to a reduced peak external knee rotation - more on that later. Women also have a greater amount of tibial external rotation during the stance phase. 

All combined, this may result in joint misalignment and subsequent knee pain.

On top of this, a greater knee abduction - seen in most women - also adds to the stress applied to the patellofemoral joint during the run.

To sum it up

Women have a “natural” tendency for joint misalignment and increased loads, exacerbated by the running activity.

Common running-related injuries – the knee

Almost half of the overuse running injuries are located at the knee. Patellofemoral pain - or PFP - is the most common, followed by iliotibial band friction syndrome - ITBS -, meniscal injuries and patellar tendinitis.

Among other common runners complains, we can describe plantar fasciitis, Achilles tendinitis, gluteus medius and hamstring injuries, as well as tibial stress fractures.

Even though very few overuse running injuries have an established cause, the fact that 80% occur below the knee suggests the existence of common mechanisms. 

Finding the root cause of an injury is often a challenge, but within the next few posts, we are gonna try to outline the mechanics and interrelationships between strength, alignment, and flexibility for the 2 most common injuries runners have to face: PFP and ITBS.

Understanding more will help you to get why certain areas of your body require more attention than others. Attention to details can make a big difference in your recovery, or even prevent you from getting injured in the first place.

Stay tuned to learn more about these!

Joseph March
Founder and Physiotherapist

After graduating from university in Australia, Joseph had solid exposure in a wide range of areas including professional sports, neurological, pediatrics, gerontology, and rehabilitation.

Joseph has over a decade of experience in Hong Kong, specializing in rehabilitation of musculoskeletal and sports injuries. He has treated issues related to pregnancy, desk jobs, as well as the unique injuries that come with a variety of athletic pursuits.

He has partnered with the Hong Kong Football Club as the performance squad physiotherapist, as well as the Hong Kong Ballet as the consulting physiotherapist.

Joseph’s hobby outside of work is the pursuit of a better functioning body. This has led him to delve deeply into many types of exercise and performance training. He has years of experience in Olympic weight lifting, movement training, powerlifting, yoga, pilates and strength, and conditioning. Through his own journey, Joseph has positioned himself well to understand other bodies and across a wide range of exercise and sport.

In the past Joseph competed at a high level in football and long distance running.

Cardeux Nel
Senior Physiotherapist

Cardeux represented South Africa and attained her first karate world championship medals at the age of 11. Cardeux’s other sport of interest is field hockey, which she has also played at a national level. From a young age, she attended physiotherapy to enhance performance and recovery. Understanding the importance of this stimulated her to pursue a career in helping others.

After graduating from The University of The Free State in South Africa, Cardeux spent a few years working in private practice as well as gaining experience in sports physiotherapy. She assisted with the Springboks in the lead up to the 2015 Rugby World Cup and worked at the Comrades Marathon for 4 consecutive years.

Cardeux’s treatment is focused on exercise, education, and a holistic therapy approach. As a keen trail runner, she specializes in performing full running assessments, both clinical and video. She has also completed her post-graduate course in Dry Needling which she provides as part of her treatments.

Cardeux spends her time off continuing to pursue sports-related endeavors. She is captain of the Valley Premier women’s field hockey team, coaches running, and manages the Hong Kong Sports Clinic running team. She also extends her passion for the sport by giving back, as a member of WISE HK – Helping empower, educate, and connect women and girls through sport in Hong Kong.


Pronouns: she/her

Elaine Leung
Principle Chiropractor

Elaine completed her chiropractic training at Macquarie University in Sydney, Australia with a Bachelor’s degree in Chiropractic Science and Master’s degree in Chiropractic. She then moved to Hong Kong to pursue her career and to promote the importance of health and the work-life balance.

Coming from a family of martial artist and traditional Chinese lion dancers, Elaine also developed an interest in Muay Thai, BJJ and weight training. This of course also comes with some injuries which have always been managed with chiropractic.

Her long interest and love for animals have then lead her to complete a Certificate in Animal Chiropractic in the USA to enable her to provide care for animals as she does for people. She is passionate about getting people (and animals) out of pain and living their lives to the fullest.

Emma Piachaud
Senior Physiotherapist

Emma returned ‘home’ to Hong Kong in 2011 after having spent her childhood here. She completed her Bachelor’s Degree (Hons) in Physiotherapy in the UK and has subsequently worked in the UK, France, and Hong Kong in a variety of settings, including the National Health Service, private hospitals and clinics, and a ski resort.

Emma is a keen sportswoman, which has led to a natural interest in sports injury rehabilitation and exercise-based therapy where she has completed many postgraduate courses specialising in manual therapy and core stability retraining. These have been in areas such as the lumbopelvic complex and thoracic rib cage and their combined effects on the musculoskeletal system. She has used this knowledge when treating clients, from elite athletes with chronic overuse injuries to postnatal women returning to sport.

Emma is available to assess and manage all musculoskeletal conditions including neck and back pain, sports injuries, thoracic and ribcage issues, and post-surgical rehabilitation. In addition, Emma has a specialist interest in treating specific problems related to ante and post-natal women, including pelvic girdle pain, rectus diastasis, mastitis, and assisting in return to sport and fitness.

Katia Kucher
Principle Nutritionist

Katia is a nutritionist with a Precision Nutrition certification and NASM Sports nutrition certification. Katia has also been a fitness, road, and trail running coach for many years. Her focus is on finding the ideal personalized diet plan to maintain a healthy lifestyle. Her other certifications include NASM Personal Trainer, PTA Global Personal Trainer. She also does corporate talks and presentations about nutrition and fitness.

As a nutritionist, her goal is to create a personalized nutrition plan and diet to help clients reach their health and fitness goals, or resolve any health issues. The key is to find a healthy, balanced, life sustainable diet that is adaptable to the client’s body type, metabolism, and lifestyle. For athletes, she creates nutrition programs to improve their performance, strength and endurance levels, and promote faster recovery.

Her background also includes helping clients dealing with injuries, by recommending a diet and specific foods that follow the healing phases to help with the healing quality and speed.

If you find it challenging to find a proper diet that will help you reach any of your goals, Katia can help you achieve your goals or help with any health issues, by recommending a diet you will enjoy and be able to maintain.

Taras Makarenko
Principle Osteopath

Taras is the Principal Osteopath with the Hong Kong Sports Clinic, where he specialises in mechanical pain associated with sports injuries, “desk-bound” related back pain, and nerve entrapment syndromes, like sciatica pain.

He has post-graduate training in both pre and postnatal as well as infant and newborn treatments. His experience includes over 6 years as an independent osteopath, working with multi-disciplinary fields alongside general practitioners, sports doctors, and physiotherapists to provide a higher level of effective recovery for his patients. He has engaged with high-level athletes in the field of tennis, soccer, rugby, field hockey, basketball, dance, ballet, trail-running, and triathletes.

To achieve long-lasting results, Taras strongly believes that structure and function have to be considered equally. His methodology includes an emphasis on educating patients about their pain, and to consider that effective recovery and treatment extends beyond the therapy room. Education is a key component to treatments when walking with patients for their road to recovery, with a mixture of in-clinic and home exercises (stretches and strength focused) as keys factors to improve symptoms.

A French national, he enjoys the fast-paced environment of Hong Kong, with his two kids and wife his loves alongside a keen interest in tennis and running.

Hamish Dickie
Senior Physiotherapist

Hamish originally undertook a Sports Science degree at Otago University and followed this up completing a physiotherapy degree at the Auckland University of Technology. A proud Kiwi, Hamish has worked with a number of high-performance teams and individuals and was part of the New Zealand Olympic team in 2018 where the team won 2 medals.

The first NZ Winter Olympics medals in 26 years. Hamish is still involved with the New Zealand Olympic program and physiotherapist for the Hong Kong Rugby men’s team. In 2018, Hamish’s wife Alex gave birth to the couple’s first child Charlie who has quickly become the apple of his father’s eye.

Prior to Hong Kong, Hamish and Alex spent a number of years in beautiful Queenstown, New Zealand where he developed the regions first high-performance youth sports academy to progress talented athletes. Hamish has worked in other high-performance programs including the New Zealand Baseball team and has worked at major tournaments such as the New Zealand Golf Open.

He has also worked in house at CrossFit boxes and is enjoying working with the CrossFit and weightlifting community in Hong Kong. Hamish was the physiotherapist for the Hong Kong Cricket Club rugby section in 2016/17 and is an active member of the cricket section where he captains the Optimists Sunday premier league team. An avid fitness enthusiast, Hamish loves all the running options that Hong Kong offers and is an avid runner on the wonderful trails.

Needless to say, Hamish understands sports and has a special interest in biomechanics and strength and conditioning components of rehabilitation. Hamish is also a qualified dry needling technician and uses a number of mobilizations, soft tissue and active release techniques to enhance the recovery process. Whether you’re a weekend warrior, youth athlete trying to reach the pinnacle of your sport or an international athlete Hamish is the right physio for you.

Charles Wang
Senior Physiotherapist

Charles completed his Physiotherapy degree at the University of Sydney, Australia. Charles has a particular interest in the link between biomechanics and injury, especially in the lumbopelvic area and lower limb. As such his treatment approach incorporates manual therapies and exercises prescription to optimise movement patterns and to recover from and prevent recurring injuries.

Joe Zhang

Joe graduated from the University of Sydney and has worked with a variety of athletes and programs, particularly at the Olympic and Professional level. He was a physiotherapist at the NSW Institute of Sport, working across all the programs in particular the Cycling, Hockey and Wheelchair Basketball programs.

Joe was also a team physiotherapist at the NSW Waratahs Super Rugby team and Sydney FC’s W-League team. He worked also as a state program physiotherapist in gymnastics and netball.

Joe’s treatment approach incorporates soft tissue release, dry needling, mobilisations and exercise prescription to speed up recovery, optimise movement patterns, and prevent injuries from recurring.

Joe has played representative basketball, and was also involved in weightlifting.

Dereck Fu



Dereck completed his physiotherapy training at the Hong Kong Polytechnic University. After graduation, he started practicing in a public hospital where he had extensive experience in treating different musculoskeletal, orthopedics, and sports conditions. He recognizes the complex contribution to pain and musculoskeletal injuries and is keen on using a wide range of skill sets such as exercise therapy, manual therapy, and acupuncture tailored to individual conditions.

Before joining HKSC, Dereck completed his Master of Clinical Physiotherapy (Musculoskeletal Physiotherapy) and accreditation in Level 1 strength and conditioning coach under the Australian Strength and Conditioning Association (ASCA). These exposures enriched his practice, considering the psychosocial, biomechanical, and training load aspect of the clients’ story.

He has a particular interest in treating sports-related injuries and desk job conditions, assisting clients on their way back to function, and prevent recurring injuries.

Dereck has been a sports enthusiast since his teenage years. He is a keen football (soccer) and badminton player who treasures the enjoyment and satisfaction brought by both team and individual sports.

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