Chronic knee pain, often caused by sprained or strained ligaments, cartilage tears, tendonitis, or arthritis, is one of the leading causes of functional limitations and disability in older adults. The onset of knee pain is associated with a reduction of physical function and can be used as a strong predictor of future disability and dependency. 

Due to chronic knee pain being the single most common cause of disability, many rehabilitation specialists consider running backwards, or “retro-running”, as a means of balancing the quadriceps muscles with the posterior chain in order to mitigate the symptoms of chronic knee pain (Rasica, et al, 2020). 

Fitness influencers and exercise specialists also suggest that adding posterior chain exercises and workouts, including the backwards sled pull or backwards sled drag, promote the same benefits of running backwards.

While balancing out the quadriceps muscles with the muscles of the posterior chain by incorporating posterior chain exercises might seem like a reasonable approach, we at Functional Patterns find that simply adding more exercises without accounting for the biomechanics of running is an inefficient and unsustainable approach to health and regeneration.

With so many influencers and exercise specialists suggesting that running backwards is beneficial for knee health, does it actually address the root cause of knee pain? What are the actual benefits of retro-running? And lastly, is running backwards a sustainable method when it comes to addressing joint pain?

In this article, we will assess the “benefits” associated with backwards running, look at how early humans evolved in nature while running backwards and forwards, and provide more effective alternatives to address the root cause of knee pain from running.

Retro-Running: Unconventional Joint Relief

Running backwards has been adopted lately by many people as a way to combat the rising rates of chronic knee pain in the active population (Gondhalekar, et al., 2013). Many studies have found these positive outcomes associated with a participation in retro-running:

1. Muscle Balance and Strength: Involves a different set of muscle groups compared to those used in running forwards.
2. Coordination and Balance: Because our eyes are on the front of our head, one must be more aware of their surroundings when running backwards, creating heightened proprioceptive concentration and coordination while constantly looking behind you.
3. Injury Rehabilitation: Due to involving a different set of muscle groups, may reduce strain on troublesome joints caused by traditional forward running.
4. Increase in Energy: Expenditure: More physically demanding compared to forwards running, thus burns more calories in a shorter period of time. 

Many of these benefits may seem like desirable outcomes on the surface; however, these outcomes are very short-sighted in their approaches.

We will investigate these benefits and explain our stance on why these outcomes may not be as helpful as one may think.

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Muscle Balance and Strength

The first benefit associated with retro-running is its correction of muscle and strength imbalances, because running backwards loads the muscles differently than running forwards. 

This intuitively makes sense since most people are told that their pain can be mostly attributed to an imbalance of muscle development; therefore, by running backwards, one would assume more contribution from the dormant muscles of the posterior chain and loading of the quadriceps muscle in a slow, controlled manner.

Unfortunately, this is only a small factor in fixing the root cause.

Most people’s skeletal structures are spiraled in one direction. This can cause a person’s whole body to be slightly rotated to the right or the left, causing most movements to overdevelop certain muscle groups due to this asymmetry.

While certain muscle groups are engaged during the movement, all the muscle fibers are not being engaged equally. This means that even when switching to running backwards in hopes of loading the quadriceps and posterior chain in a different manner, the asymmetrical spiral pattern of the structure will most likely still cause activation of one leg more than the other and only partial recruitment of those muscle fibers.

This will further ingrain the asymmetrical spiral pattern in the structure, creating more dysfunction that the body will need to compensate for later down the road.

Coordination and Balance

Another benefit that is attributed to running backwards is the heightened proprioception and awareness one must employ while running in a direction that one cannot see clearly.

The most fundamental flaw of running backwards is that you cannot see what is behind you without constantly having to look where you are going in order to avoid incoming obstacles that might be present, leading to an elevated risk of injury due to hazards from tripping and falling. 

This will also alter the way our head is supposed to be moving while running forwards. By changing the direction of our movement, the direction our head is facing will ultimately cause a compensatory structural change of the rest of the body, leading to further dysfunction somewhere else.

Injury Rehabilitation

Probably the most popular benefit one typically strives for when employing backwards running is to relieve joint pain in their knees by shifting the stress of impact loading from the muscles of the quadriceps and patellar tendon towards the glutes, hamstrings, and calves. 

Trying to alleviate joint pain is a valid intention but the methodology lacks foresight.

As we discussed earlier, the body already has a predisposition to be spiraled in one direction, causing an asymmetry in the skeletal structure. 

While instituting backwards running, this asymmetry will cause the tension associated around the knee to be applied on the posterior chain without addressing why the knee joint is not efficiently absorbing impact from running forwards. 

This avoidance of addressing the root cause may allow relief for the short-term but the pain may eventually come back or worse, another part of the body may have to compensate and in turn, show symptoms of dysfunction as well. 

By simply changing the direction of running instead of addressing the biomechanics of running, the structure will continue to ingrain dysfunctional patterns of movements in whichever direction you choose to move.

This will most likely just shift the pain from one area of the body to another without fixing the actual problem, like kicking a can down the road instead of picking the can up and putting it in a garbage bin.

Increased Energy Expenditure

The last benefit usually associated with running backwards is the increased amount of calories burned due to the inefficient way of moving the body in space. 

This might seem like a positive outcome for many, however we’d like to ask the question of whether decreasing movement efficiency in order to counteract the effects of consuming an excess amount of calories is a sustainable strategy.

Typically, poor biomechanics can be a leading cause as to why someone may struggle with maintaining low body fat. 

If a person moves poorly, they will be only using certain muscles to drive that movement and will rely on those same muscles over and over again. This might cause them to have a very low basal metabolic rate as the majority of their muscles are not being used efficiently and remain dormant and atrophied. 

Many people will then combat this by doing more exercise or making certain exercises less efficient and more strenuous in order to increase energy expenditure, to burn off the excess calories that they consume. 

This could lead someone down a vicious cycle of exercising excessively as a coping mechanism for their poor eating habits, and hitting a struggling point when they inevitably get injured and cannot exercise to maintain this dysfunctional cycle. 

This willingness to exercise but being limited due to injury and pain can lead to anxiety and depression in many exercise addicted individuals (Lichtenstein, et al., 2018)

So what is the solution then? 

Should people just give up hope and get surgery for their knee pain or take some painkillers and keep pushing through?

How does one begin to correct how they run?

We should first understand the important correlation between humans and running, and how it enabled us to be such a dominant species in nature.

Addressing the Root Cause: First Principles Approach

At Functional Patterns, we believe that correcting your biomechanics is integral to a healthy body and a healthy mind. 

By addressing the root cause of their knee pain, one may add many more sustainable years to their running career as long as the priority is to improve the WAY they run, instead of which direction they run. 

Running is an important part of the history of the human species. Our ancestors evolved to run as a means of survival for millions of years in nature to hunt down prey, flee from predators, and migrate across various terrains.

This is why at Functional Patterns, we have included running as one our FP First Four (standing, walking, running, and throwing). 

Humans evolved to have a long Achilles tendon with short toes which allow elasticity of the ankle joint for efficient forward propulsion when running and scavenging (Schulkin, 2016). This long, elastic tendon accompanied with strong gluteal muscles and a narrow pelvis allowed humans the ability to run for long distances or sprint in short bursts.

Now, running backwards is a useful skill to have, particularly when maneuvering in tight spaces or during combat, but we did not prioritize running backwards due to the anatomical constraints of our eyes being placed on the front of our head. This means that we evolved to run forwards as a means of navigating and coordinating our movements to interact with the environment we see in front of us. 

Also, while there were times when walking or running backwards allowed us to retreat and keep our eyes focused on the danger ahead of us, it was dangerous to move in inefficient manners due to the metabolic demands of our large brains. Our brains required massive amounts of energy to maintain their activity in dealing with the elements of survival, so natural selection favored those with efficient mechanics (Schulkin, 2016).

The more efficient a body can move through space, the more functional the architecture within the brain. Bilateral hippocampal volume as a function of aerobic fitness group. (Schulkin, 2016)

Therefore, we should be prioritizing our ability to run forwards and improve the way our structure interacts with gravity, as running is the expression of our evolution and helps to improve our ability to learn (Schulkin, 2016).  

So now that we understand that our bodies evolved to run forwards primarily, we can see why retro-running, backwards sled pulls or sled drags will most likely not fix the root cause of knee pain but only provide short-term relief.  

So what are some posterior chain exercise alternatives that we can do instead?

FP Alternatives for Posterior Chain Development

Addressing knee pain by adding backwards sled drags and sled pulls without assessing a client’s gait cycle would be like throwing a bunch of ideas at a wall, hoping something sticks. 

It is important to first get assessed by a verified FP Human Biomechanics Specialist or film yourself running and compare yourself to high-level sprinters. 

Do your sprint mechanics match those of a Usain Bolt or a Barry Sanders? 

If not, then applying FP concepts and exercises found in the 10 Week Online Course will set you on the right path. 

One of the exercises found in the 10 Week Online Course is the contralateral step row and is a great example of an exercise that not only rehabilitates the knee, but also integrates the lower body with the upper body.

This exercise focuses on developing not only the glutes, hamstrings, and calves of the posterior chain, but also integrating them with the muscles of the low, mid, and upper back like the spinal erectors, lower to upper trapezius, and latissimus dorsi with the rotation of the pelvis and ribcage. 

As well, the posterior and anterior oblique slings will be connected across both the back and front of the body at the same time to promote integrated trunk rotation. 

These integrated movement patterns can also be practiced by executing medicine ball slams, pendulum swings, contralateral split steps, and many more exercises as instructed in the Functional Training System online course. 

  Pendulum Swing Step from Functional Training System

All of these components need to work together while running, so it is important that they move in the correct sequence and ratios as shown in the 10 Week Course or Functional Training System to improve the way your knee interacts with the ground when running either forwards or backwards.

Without accounting for the fundamental concepts laid out in these courses, posterior chain exercises like sled drags or backwards sled pulls will be applied in a sloppy manner which could lead to more injurious compensations down the road. 

Conclusion

Chronic knee pain is one of the leading causes of disability in older adults. Many active runners develop pain in their knees and have been advised to participate in backwards running or retro-running as a means of balancing the muscles of the quadriceps and the posterior chain.

Simply adding posterior chain exercises, such as backwards sled drags or sled pulls, along with running backwards is an ineffective way to mitigate chronic knee pain.

We at Functional Patterns find this to be a short-sighted approach, as the short-term relief could potentially cause more drastic issues down the road due to the anthropological evidence that humans and their early ancestors evolved to run forwards.

The body has evolutionarily adapted to running forwards, therefore we must prioritize our training around the FP First Four so that we can navigate in our environment and propel our bodies forward through space as nature intended. 

Resources

1. Gondhalekar, G. A., & Deo, M. V. (2013). Retrowalking as an adjunct to conventional treatment versus conventional treatment alone on pain and disability in patients with acute exacerbation of chronic knee osteoarthritis: a randomized clinical trial. North American journal of medical sciences, 5(2), 108–112. https://doi.org/10.4103/1947-2714.107527
2. Lichtenstein, M. B., Nielsen, R. O., Gudex, C., Hinze, C. J., & Jørgensen, U. (2018). Exercise addiction is associated with emotional distress in injured and non-injured regular exercisers. Addictive behaviors reports, 8, 33–39. https://doi.org/10.1016/j.abrep.2018.06.001
3. Rasica, L., Porcelli, S., Minetti, A.E. et al. Biomechanical and metabolic aspects of backward (and forward) running on uphill gradients: another clue towards an almost inelastic rebound. Eur J Appl Physiol 120, 2507–2515 (2020). https://doi.org/10.1007/s00421-020-04474-7
4. Schulkin J. (2016). Evolutionary Basis of Human Running and Its Impact on Neural Function. Frontiers in systems neuroscience, 10, 59. https://doi.org/10.3389/fnsys.2016.00059