When in Doubt, Knee-Out: Knee Alignment for Runners

Stay the CourseThe knee is the keystone joint of our running system. A knee that can flex, extend, rotate, and torque is the key to our running speed and freedom. But with great mobility comes great responsibility! How we control the knee in space plays an important role in our ability to run efficiently and avoid aches, pains, and potentially serious injuries.

This article serves as a primer on knee alignment. We talk about its role in efficient, fast, and strong running; its underpinnings in most runners’ injury and performance issues; and how we can adopt neutral knee alignment. The goal is to help you run healthfully and successfully.

A Note on Efficient Alignment: Least Stress and Most Power

A pillar of postural-efficiency theory is that the neutral position allows for two key functions:

  • Neutral alignment promotes minimal strain as energy can enter and leave the body with minimal stress-inducing absorption; and
  • Neutral alignment promotes maximal power and endurance as a movement pattern fires most automatically with maximal strength.

First, a congruent, linear alignment of body segments allows for the gravity- and movement-driven flow of energy through the body. Ground impact drives upward into the body, and trunk and limb energy flows outward toward the ground. If our body and its pieces are linearly and congruently aligned, this energy can flow in the freest manner possible.

Second, neutral alignment allows for optimal muscle function. Not only does it allow for balanced, reciprocal muscle activation, but it also allows all relevant muscles in a movement pattern to activate both optimally and maximally. To put it more plainly, a neutral system generates the best, strongest, and most effortless function.

While finding and maintaining neutral can be a challenge, the payoff is substantial.

Neutral Knee Alignment

There are three general knee-alignment positions in the frontal plane:

  1. Knee-out/varus alignment, where the knee is excessively outward angled;
  2. Knee-in/valgus alignment, where the knee is excessively inward angled; and
  3. Neutral, which is the midline between the two extremes.

Clinically, I teach neutral knee alignment as the midline alignment of the patella (kneecap) over the second and third toe interspace. This position generally places the knee in the center of a line drawn from the hip joint to the midpoint of the foot.

Knee-out/varus alignment. All photos courtesy of Joe Uhan unless otherwise noted.

Knee-in/valgus alignment.

Neutral knee alignment.

In my clinical experience, knee-in/valgus alignment is far more common and problematic for runners. A few runners demonstrate an excessive knee-out/varus alignment, but this is exceedingly rare. Of inefficient knee alignment, I see 90% with valgus and 10% or less with varus. Knee valgus is a common, if not rampant, inefficiency across all sports.

Why is valgus far more common? It’s tough to say. A knee-in position is related to a passively collapsed, overstretched posture. Thus, our inability to maintain knee neutral may be related to factors such as excessive sitting, a lack of extensor-pattern muscle-group strength (which includes the glutes and hip external rotators), or both.

The “Unholy Rotation”

Prolonged function–standing, stepping, squatting, jumping, or running–in a knee-in/valgus position creates some pesky compensatory problems from the trunk down to the foot. The “Unholy Rotation,” as I call it, results in the following rotational compensations in these body segments:

  • Pelvis – External rotation
  • Hip – Internal rotation
  • Tibia  – External rotation
  • Rearfoot – Internal rotation
  • Forefoot – External rotation
  • Arch – Pronation

The “Unholy Rotation.” Image: Posturedirect.com/wp-content/uploads/2017/01/characteristics-of-knee-valgus.jpg

This coupled rotation is the body’s attempt to gain passive stability in a weakened system. In essence, the joints rest upon one another, but in a twisted, wrung fashion. As you might imagine, this not only results in passive stress but also inhibits automatic muscle function in the leg. In short, it’s bad news! Severe valgus with full-bore unholy rotation is somewhat rare, in part because a runner with this alignment seldom can run very far before injury. Milder–but still problematic–knee valgus is far more common and can create myriad aches, pains, injury, and performance issues.

The Consequences of Knee Valgus

Knowing the importance of efficiency, the consequences of knee valgus are straightforward. Knee-in alignment causes impact strain throughout the chain, including:

  • Joints – Aches, pain, and/or injury
  • Pelvis – Hip and low-back pain
  • Hip­ ­– Lateral hip (trochanteric bursitis) and iliotibial (IT) band pain
  • Knee – Patellar or knee-joint injury (on the medial and overstretched side that can be “pes anserine bursitis” whereas on the lateral and compressed side it might be “IT band” issues)
  • Shin/Ankle – Medial shin pain (shin splints, posterior tibilalis pain, and/or stress fractures)
  • Foot – Plantar foot pain (plantar fasciitis)

But even for those runners who have minimal issues due to knee valgus, it is still an efficiency drain. A knee-in mal-alignment may lead to the following inefficiencies:

  • Foot arch collapse/“overpronation;”
  • Deficient ankle strength and stability in the stance phase;
  • Deficient knee stability or too much bend in the stance phase; and
  • Deficient glute activation and weakened push-off.

That can lead to a lot weighing on one joint!

Compensatory Valgus: Crossover (Narrow) Landing

You’ve seen pictures of your running stride. Your knee is straight; it doesn’t bend in. You’re in the clear, right? Look closer. Where does your foot land? If it crosses midline, you’re in trouble. Neutral alignment of the leg is a straight line connecting the midpoints of the hip, knee, and foot–with the foot landing at midline. A foot that crosses beyond midline and lands on the opposite side of the body creates similar problems as valgus with excessive tissue strain, and impaired landing and push-off strength.

It is my theory that an excessively narrow, crossover landing is a compensation to avoid knee valgus (and is a revision of my initial theories about stride width). Valgus–particularly dynamic valgus, where the foot lands and the knee torques into greater valgus from initial contact to mid-stance–is both stressful and threatening to stability and joint integrity. To avoid this threat, the brain will compensate by landing excessively narrow.

This geometry avoids valgus torque, but at the expense of impaired landing and push-off efficiency. A narrow landing creates excessive landing stress along the entire lateral side of the leg. Like an imbalanced tire, a narrow-landing runner rides the outside edge of the foot and overloads the entire lateral leg. Runners with a crossover landing pattern tend to accumulate aches, pains, and injury along the lateral foot, ankle, shin, knee, thigh, and hip.

But what lands laterally must eventually hit the ground. Narrow, lateral overloads also create hyper-pronation, bringing with it all the problems of pronation to the medial side of the leg, including plantar fasciitis, shin splints, and medial knee pain, to name a few.

A narrow, crossover landing, like most compensations, may help keep a runner upright and more stable, but it’s possible that this compensation is more damaging than valgus. Tires aren’t meant to ride the edges, and neither are legs. The imbalanced loading can create chronic instability to every joint in the system, from foot to hip.

Beyond that, a hyper-narrow landing is a major efficiency drain. While mid-stance stability is arguably better with less passive give, the stance leg is so narrow that it lacks the ability to efficiently push off as the foot, ankle, and hip aren’t able to powerfully plantar flexion and extend. Compensations also occur at the contralateral hip flexion, which must work harder to flex beyond the hyper-narrow and crossover landing.

So, what fixes a crossover landing pattern? It’s taken me years of trial and error, but the most potent solution is knee-out alignment. Promoting neutral knee alignment and avoiding valgus usually results in a near-full correction of stride width and the problems that come with it.

Exercises that Promote Neutral Knee Alignment

Training neutral knee alignment is a concert of strength and stability at the foot and ankle as well as at the hip. My favorite functional knee alignment exercises include:

What all these exercises have in common are a strong foot at the base, coupled with a balanced trunk and pelvis, and a hip hinge which work together to create a knee-out, neutral knee alignment.

Putting it Together: Mindful, Knee-Aligned Running

When it’s time to apply it to running, a knee-out strategy must be an intentional one. Athletes sometimes believe that exercise alone is enough to overtly change the running motor plan. Too often, it is not. Instead, a conscious and sometimes awkward effort is required to change a valgus or crossover landing to an efficient, knee-out one.

It’s simple but not easy. Efficient landing has the foot landing directly beneath midline, with the knee in a straight-but-outwardly-angled line. Thus, simply running wide with the foot is not only insufficient, but might create even more valgus potential. (The wider the foot, the higher the likelihood the knee could migrate medially.) Instead, a neutral-knee strategy must be knee-out and foot-in. This is, in essence, trying to run bow-legged. Another sporting analogy: imagine striking a hacky sack with the inside edge of the foot. The key movements are an external rotation of the femur with the foot moving medially.

As awkward as this might feel, the aesthetic result is sound: an outward-aligned knee and a foot that lands at midline without crossover.

There’s a caveat to beginning this reprogramming, though. Initially, runners adjusting from a valgus or narrow landing will feel more lateral loading of the foot. This is a short-term issue that will decrease as the whole leg de-rotates out of the Unholy Rotation.

Neutral Knee Benefits for Trail Runners and Ultrarunners

Besides aches, pains, and injury avoidance, the performance benefits of a neutral knee alignment for trail runners and ultrarunners are numerous, including:

  • Increased landing stability – A knee-out landing is more stable and responsive. In particular, descents will feel lighter and more controlled.
  • Increased climbing strength – A knee-out alignment recruits more glute, quadriceps, and lower-leg muscle for push-off and upward climbing.
  • Less quadriceps overuse or blowout – More strength above and below the knee equals less quad overload.
  • Maximum speed and efficiency – Efficient landing equals better top-end speed and endurance.

Conclusion

Like any stride adjustment, adopting a more knee-out alignment is a leap of faith. But it is a gamble with a relatively small downside and a potentially huge upside that’s worth the effort and change!

Be sure to stay tuned for Part 2 with knee-alignment running-stride examples and commentary, more detailed knee-stability exercises, and advanced tips for mountain trail runners.

Call for Comments

  • Have you had pain or an injury that originated from a mal-aligned knee? If so, can you explain your diagnosis and how you were able to correct it?
  • Where do you think your knees fall in their frontal-plane alignment? Do you think you have knee-out, knee-in, or neutral alignment?
Joe Uhan

is a physical therapist, coach, and ultrarunner in Eugene, Oregon. He is a Minnesota native and has been a competitive runner for over 20 years. He has a Master's Degree in Kinesiology, a Doctorate in Physical Therapy, and is a USATF Level II Certified Coach. Joe ran his first ultra at Autumn Leaves 50 Mile in October 2010, was 4th place at the 2015 USATF 100K Trail Championships (and 3rd in 2012), second at the 2014 Waldo 100K, and finished M9 at the 2012 Western States 100. Joe owns and operates Uhan Performance Physiotherapy in Eugene, Oregon, and offers online coaching and running analysis at uhanperformance.com.

There are 13 comments

  1. Katherine

    When I first started running 4 years ago, I spent the first year with chronic pain in the outside lower quadrant of one knee. Being new to running I went to my GP who recommended a non-sport PT. Lots of back and forth between the two with no joy and two cortisone shots. But since my New Years resolution was to run a half marathon I continued to limp along. One day while running, I noticed that I kept “clipping” the inside of one ankle with the back of the heel of the other foot. Hmmm, maybe all those years of ballet and working on using my deep rotators to maintain leg rotation were now causing problems. I spent the next several months being hyper aware of where my knees and toes were pointing. I discovered that in addition to the knees pointing away from the centerline, I was landing on the outside (mid-foot, not heel) of my foot, then rolling diagonally across to push off of the inside of the big toe and big toe joint. So I embarked on a months long struggle to run with my knees and toes pointing forward (nose, knees and toes became my mantra). For about the first month I felt like I was running “pigeon toed” and I had to keep looking down to make sure things were heading in the right direction. The second month I had to keep checking because I wasn’t getting any feed back from my muscle- it no longer felt awkward- but I couldn’t tell by feel if I was running turned out or straight ahead. By the third month I was able to trust that the nose, knees and toe alignment was happening. I actually anticipated this progression because I had experience with it in having to relearn movements in dance. The whole awkward- white noise- okay it’s working the new way without supervision progression is a common occurrence in dancers relearning steps. You just have to know that it’s going to take a while to get through the process…

    1. Joe Uhan

      Katherine-

      Thanks for the comment, and I applaud your efforts to optimize your stride.

      Given what you shared: I would be curious what would happen if:

      A. You did a step up exercise like this: https://www.youtube.com/watch?v=S54Ri95-9xU

      How is your abilty to keep your knee out (both up and slow reverse down)?

      B. You tried to run “knee out” (vs “foot in”)

      Of note: “foot out” is an outcome from the “holy rotation”. So it’s a paradox, then, that trying to do “foot in” actually can make a knee alignment *worse* (foot in = hip rotation in = usually more knee valgus).

      Knee out will ***temporarily worsen*** foot out…until that whole leg “de-rotates” (pelvis, hip, knee, shin/ankle and foot reverts to more neutral alignment).

      If you find yourself struggling to maintain knee-out with the step exercise, you might benefit from a knee-out focus in running.

      (Lastly: I offer free video “estimates” – quick opinions – on running strides on my website: shoot and upload here:

  2. Ryan Montalvo

    The detail of the information in this article awesome. Knowing what I need to be looking for in my knees to help keep them healthy is important. reading and seeing what good alignment of the knee should be will provides me with something to focus on in my running. Recently my stride has felt off and I had a bit of knee pain, my alignment might be off. I also appreciate the exercises you shared that will help with knee alignment. Thanks for a great article.
    Ryan

    1. Joe Uhan

      Thanks for the good feedback, Ryan. See my comment above: if you ever want a quick (no fee, no obligation) feedback (especially on something like knee alignment), shoot a video and upload to the link, above.

  3. Oliver

    Hi Joe
    Thanks for this interesting article. What‘s your opinion on custom orthotics re. knee valgus? Do you think it helps supporting the knee from „collapsing“ especially towards the end of a long ultra when muscles are getting tired?

    1. Joe Uhan

      Oliver-

      Thanks for the comment and great question.

      Leg alignment has been well-known and accepted as:

      1. a key efficiency for peak performance
      2. a key factor (malalignment) in injury

      for a long time.

      As such, ‘bracing” has been a popular strategy — whether that be from down below with foot orthotics, or above with knee braces, or “kinesiotape’ (support) every where in between.

      Shoe and orthotic engineering has been a huge part of this alignment strategy. But has it helped?

      Not really. The totality of evidence for shoe and orthotic engineering is “dunno” at best for efficiacy. Injury has not improved. Nor has bracing or orthotics have substantially improved ACL injury, either (more on this below).

      Why? My take:

      “A Dynamic Problem requires a Dynamic Solution”

      Shoe engineering and orthotics are passive solutions: hoping to “stack” (/ “slop”) your bones, passively, in the right alignment. But without a dynamic approach, it simply doesn’t work (instead,the joints often counter-slop to the opposite direction, or fail to move in an efficient way).

      As such: while they can be useful for more severe hypermobility cases (both in the feet and knees/hips), orthotics/shoe engineering is over-prescribed for an issue that is best addressed dynamically – with strength and motor control training.

      Best to get stronger and develop neutral alignment in dynamic exercise to promote healthier athletics (& running)!

  4. Greg H

    Joe:

    I’m a huge fan of your articles, which I believe challenge some modern misconceptions about running technique, posture, and propulsion—but the technique your promote is very inline with primal or natural movement patterns. These observations are based on my non-medical albeit experienced take on the framework you’ve laid out.

    What I feel is missing is some quality video of your whole running gait cycle put together. I’d really appreciate a couple of links of front and side views of you or other runners in action who demonstrate your comprehensive model. Narrated by you would be even better.

    Thank you,

    A fellow Minnesotan.

  5. Gary Winters

    Dear Joe,

    Thanks so much for this article!

    I’ve run my whole life and always been able to self diagnose and fix things before they got bad. I’ve never had trouble with my knees until this year after the winter racing season. Is there a way to wear the soles of your shoes correctly and have a stride that looks correct but still have knee pain and stride issues?…if so, I’m the one. I’d tried everything and looked everywhere without finding a fix until this article! I’ve always run “from my ankles”. In other words, I’ve always paid attention to the foot landing and the ankle position to manage gait. After reading and watching this article several times with my own practice, I’ve started running “from the knees,” making sure of the outward patellae position over the second and third toe on landing. I even had people look at me run and tell me that there was no inward roll (and no signs of that kind of wear on the soles of my shoes), but my pain went away entirely in 2 runs when I focused on what felt like Varus knee position on landing. I’ve never paid attention to my knees while running until now….what a difference!

    Here’s my one request….do you have an article or can you make one to present downhill landing drills / practices /strategies especially for steeps.

    Thanks again!

  6. Joe Uhan

    Hi, Gary-

    Thanks for the comment and great feedback. I’m encouraged that you’re feeling better with the knee-out adjustment!

    I’m planning on a Part II for this piece that contains some stride examples (and commentary), as well as some exercises and drills, and – hopefully – notes on downhill, too.

    Stayed tuned for a couple weeks!

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