The Austin Marathon takes place this year on February 16th. During this time of year, as many runners’ seasons are peaking with participation in this race, we typically get a lot of questions at Symmetry about “Runner’s Knee” and other pain and injury issues frequently associated with high-mileage running. We hope that if you are a runner, you are running without pain and are poised to have a great race! We also thought that the occasion might be a good time to present this adaptation of an article published this past fall by a physical therapist named Heidi Dawson that works with runners in the United Kingdom.
IT Band Syndrome is the most common cause of knee pain in runners and accounts for up to 14% of all running injuries. It is generally more common in males than females. Typically pain resulting from this injury is present on the outside of the knee, and occurs as the knee begins to bend while under load, especially as the hip is moving from the front of the body towards the back – as during a walking stride. In runners, this type of knee pain occurs most frequently during downhill running or while going down stairs. Pain is usually described as sharp or stabbing and gets worse with continued activity. Eventually, the pain often leads runners to stop running altogether.
There has been a huge misconception over the years about the cause of this lateral knee pain condition. It was in fact once known as “Iliotibial Band Friction Syndrome,” because it was thought that the pain was the result of the bottom end of the IT band “flicking” back and forth over the outside of the knee, causing irritation and inflammation on the underside of the band. We now know this is not the case.
The IT band is pretty well tethered to the kneecap and to the lower end of the femur (the upper leg bone). Because of this, there is no “flicking” motion of the band. Instead, the pain issue in IT Band Syndrome is believed to be due to compression of the band against the sensitive fatty padded tissue underneath.
IT band pain is often a result of a training load error. Usually, a runner with pain has recently had a rapid increase in running distance or has been running more downhill or on trails than he/she was previously accustomed to doing. Other factors which may increase the likelihood of developing this condition are:
- A narrow step width – which increases load on the IT band and so increases compression
- Increased hip abduction levels – which also loads the IT band excessively
IT Band Syndrome is a situation for which physical therapy treatment is indicated. Your therapist will evaluate a variety of things about your body structure and walking and running strides to specifically identify the mechanical issues that are causing knee pain. The best way to diagnose cases of IT Band Syndrome are by collecting a careful patient history and by ruling out other possible causes of the pain. For example, it is important to also consider the possibility of pain being referred to the knee from elsewhere. Your physical therapist can help you to identify whether or not there are any issues with your back or hip that may be contributing to the knee problem. They will also look at your foot and ankle mechanics, as well as at your shoes and any inserts that you may have.
Once all of the mechanical issues associated with IT Band Syndrome have been identified, a rehab protocol can be developed. Generally, recovery from this type of knee pain involves several phases. The first phase aims to help with pain reduction. One of the most important things which a therapist should encourage a client to do is to keep moving in some capacity. Runners will often instinctively stop running and cease other forms of exercise due to their pain. This, of course, leads to a reduction in symptoms. However, what inactivity also leads to is a loss in load and activity capacity. And so, when the runner decides to return to running, they often find that they have an even lower tolerance to running and that their pain returns even quicker. Your therapist can design an exercise program that makes sense for each patient with regard to the severity of their symptoms. It may be that some patients may be able to continue to run, using either shorter distances or flat road routes instead of rocky trails. For others, a treadmill or stationary bike workout can be utilized to maintain cardiovascular fitness as well as mental health, which can suffer when people accustomed to exercising regularly are “sidelined” due to injury. During this pain control portion of rehabilitation, strength and movement training activities can also be started via activities that do not create pain. (You may be noticing here that there has not been mention made of trying to stretch the IT band. It used to be thought that stretching an IT band that had “gotten too tight” could ease knee pain. However, we have now established that the IT band is NOT an elastic structure, but rather a thick and fibrous tissue. It cannot be “tight” and cannot be stretched. It may be that stretching activities ARE indicated for patients with IT Band Syndrome – but more likely for muscles such as the hip flexors or hamstrings.)
The 2nd phase of rehab for IT Band Syndrome can be initiated once there is no pain on the descent of stairs. Strength training during this phase can now include heavy, slow resistance training as wall as a continuation of uphill treadmill walking or some other similar form of non-impact aerobic activity. Split squat progressions are an example of appropriate exercise for this phase.
The 3rd stage of rehabilitation includes the addition of plyometrics or “jump training” to work on improving the power of the IT band prior to actually running. Lateral step-hops using a resistance band are an example of this type of activity.
A 4th stage of rehab involves the initiation of a return to running program. Treadmill running is highly recommended for the initial stages of this part of therapy, as incline can be controlled, and the session can be stopped immediately if any symptoms arise. In a typical return to running program, each session begins with a walking warm up and ends with a walking cool down. In between these intervals, a patient might run 1 minute and then walk 2 minutes for a particular number of repetitions. Gradually, the running intervals are increased while the walking intervals are decreased until longer running intervals are comfortable.
A final stage of rehabilitation would be to transition a patient’s running back to the environment which was previously typical. This would involve moving running workouts from a treadmill to a road surface or trail – again via some sort of prescribed progression.
In summary, the knowledge we have surrounding the cause, assessment and rehabilitation of IT Band Syndrome has progressed considerably during the last few years. What was once thought to be a friction injury is now believed to be due to compression. The way we assess the injury has changed. And rehabilitation has also changed, with athletes advised to continue moving and loading the involved structures in a pain free manner, and then to steadily increase the load capacity of the injured tissue as the goal of a gradual return to running is achieved.
Do you have knee pain or questions about how to manage other running-related issues? If so, we encourage you to contact your therapist at Symmetry. We’d be happy to get you started running down the road to recovery!