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Can marathon running benefit your knees? A deep dive into the impact of long-distance running on knee health

9th Oct, 2023

Key Points:

  1. Mixed effects on knee structures: MRI scans revealed both positive and negative changes in knee structures among novice marathon runners. While subchondral bone health improved, cartilage damage worsened.
  2. Asymptomatic impact: The study highlighted that many structural changes occurred even in the absence of symptoms. This underscores the complexity of knee dynamics and challenges traditional assumptions.
  3. Injury prevention and training: The findings emphasise the importance of injury prevention strategies, gradual training, and proper biomechanics. Marathon runners can benefit from tailored approaches to knee health.


With the growing popularity of long-distance running, particularly marathons, there has been an increasing concern about the potential impact of this strenuous activity on knee health. This study delves into the relationship between marathon running and knee joint health, shedding light on whether the sport has positive or negative effects on middle-aged adults’ knees. In this article, we’ll explore the findings of a groundbreaking prospective cohort study that evaluated the short-term impact of marathon running on knee joints using advanced MRI technology.

The study and its objectives

The study focused on 82 healthy adults who were embarking on their first marathon journey. Advanced 3T MRI scans were conducted on both knees of these participants six months before the marathon and again half a month after completing the marathon. The aim was to assess any structural changes in the knee joints caused by marathon training and running. These changes were evaluated by senior musculoskeletal radiologists using validated scoring systems, and participants also self-reported knee function using Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaires.

What did they find? 

Before delving into the results, it’s important to note that even before starting marathon training, many participants already showed signs of knee structural damage on MRI scans, despite not experiencing any symptoms. After completing the marathon, the MRI scans revealed both positive and negative changes in various knee structures.

Positive findings

Subchondral bone improvement: 

The study found that novice runners experienced improvement in subchondral bone health in certain areas of the knee, specifically in the condyles of the tibia and femur. This indicates that long-distance running might have a protective effect on these weight-bearing areas of the knee.

Meniscal tears: 

Contrary to concerns, the study showed that having meniscal tears did not prevent participants from successfully completing the marathon. This suggests that asymptomatic meniscal injuries can be managed conservatively, without the need for immediate surgical intervention.

Negative Findings

Cartilage damage:

Interestingly, marathon running seemed to worsen cartilage damage in the patellofemoral joint, particularly the lateral patellar facet. While this may raise concerns, it’s essential to note that these changes occurred even in participants who did not experience symptoms.

Other structures:

The study also found increases in tendon injuries, prepatellar bursitis, and iliotibial band friction syndrome (ITBFS) after the marathon. Again, it’s important to highlight that these changes were observed without corresponding symptoms.

Clinical implications for you and your Physiotherapist

The study’s findings have several important clinical implications for both runners and Physiotherapists:

Subchondral bone health: 

The improvement in subchondral bone health suggests that marathon running might have a protective effect against the onset of osteoarthritis. This insight could influence exercise recommendations for knee joint health.

Cartilage health: 

While the study observed worsening of cartilage damage, it’s important to remember that this damage occurred in asymptomatic individuals. The findings suggest that cartilage changes might not necessarily lead to immediate symptoms or functional limitations.

Tendon and soft tissue injuries: The increase in tendon injuries and soft tissue conditions like prepatellar bursitis and ITBFS highlights the importance of injury prevention and proper training techniques.

Injury prevention strategies for runners

To ensure the safety and long-term knee health of marathon runners, injury prevention strategies are crucial:

Proper training: 

Gradual and structured training programs can help prepare the body for the demands of marathon running, reducing the risk of overuse injuries.

Strength training:

 Incorporating strength training exercises that target the muscles supporting the knee joint can provide added stability and reduce the strain on knee structures.


 Engaging in low-impact cross-training activities can help alleviate the repetitive stress on knee joints while maintaining cardiovascular fitness.

Biomechanics assessment: Runners can benefit from a gait analysis to identify any running form issues that might contribute to knee problems. Customised interventions can then be recommended.

Running knee pain in Singapore

In Singapore, knee pain when running is a concern for many individuals. While this study didn’t specifically analyse data from Singapore, its findings are applicable to runners in the region. The insights into knee joint health after marathon running can guide runners in Singapore to make informed decisions about their training and participation in long-distance events.


In conclusion, the study provides valuable insights into the complex relationship between marathon running and knee health. The findings indicate that marathon running might have both positive and negative effects on various knee structures, but these changes don’t necessarily correlate with immediate symptoms or functional impairments. Aspiring marathon runners and healthcare professionals should take these findings into account, focusing on injury prevention, proper training, and individualised care to ensure the longevity and health of knee joints.

Running is beneficial so don’t let anyone tell you otherwise! Contact us today to allow our Physiotherapists to address your knee pain as we address any of the strength or movement deficits so that you will be able to return to running as quickly and as safely as possible!

REF: Horga LM, Henckel J, Fotiadou A, et al. Can marathon running improve knee damage of middle-aged adults? A prospective cohort study. BMJ Open Sport & Exercise Medicine 2019;5:e000586. doi:10.1136/bmjsem-2019-000586

Common Running Related Injuries in Singapore

Common questions asked about marathon running

How can I prevent knee injuries while training for a marathon in Singapore?

Marathon runners should focus on gradual training to protect their knees. It’s crucial to prioritise injury prevention by incorporating strength training, proper biomechanics, and individualised care into your training regimen. Additionally, consider running on softer surfaces like parks or trails in Singapore to reduce the impact on your knees compared to hard roads. Speak to our Physiotherapist or Podiatrist who is able to guide you on an injury prevention programme.

What are the most common running injuries among marathoners in Singapore?

There is no specific data for Singapore, but it is known that structural changes in the knee can occur during marathon training. Common running injuries worldwide often include issues like knee pain, shin splints, and IT band syndrome. In Singapore’s climate, heat-related injuries and dehydration can also be concerns, so stay hydrated and adjust your training accordingly.

How do I choose the right running shoes to avoid injuries during a marathon in Singapore?

Selecting the right running shoes is crucial. While the article doesn’t discuss shoe selection, it’s advisable to visit a specialised running store in Singapore to get a gait analysis and professional advice on shoe choices. Consider shoes designed for marathon running and suitable for the climate, providing adequate support and cushioning. Our Podiatrist is also able to guide you through a more tailored recommendation.

What is the recommended rest period between marathons to avoid overuse injuries in Singapore?

To prevent overuse injuries in Singapore’s humid climate, experts often suggest spacing marathons at least 4-6 months apart, allowing for proper recovery and training cycles.

What's the difference between overuse injuries and acute injuries in marathon running?

Overuse injuries result from repetitive stress on the body over time, while acute injuries are sudden and traumatic. In the context of marathon running in Singapore, overuse injuries may develop gradually due to high mileage, while acute injuries could result from falls or sudden strains. Understanding these differences helps in early detection and appropriate management.

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