The following post by our Senior Physiotherapist Bryan Robertson:
“I’ve decided to write this blog post due to the amount of questions and queries I get about a really common presentation from runners- lateral knee pain associated with ITBFS (Ilio-Tibial Band Friction Syndrome). Recent Physio work with marathon runners through Prosport (New York and Tokyo marathon run groups) and also a lot of trail runners asking me about injuries (Surf Coast Trail Runners group and Optimus Ambassador and World Junior Trail Champion Lucy Bartholomew).
5 Key Facts that will help your understanding will follow. If you’re a runner and you’ve had this, chances are you’ve done some sort of research on ‘the google’. Chances are, you’ve diagnosed yourself with ITBFS and you’ve also had some reassurances from fellow runners that yes, it is indeed ITBFS.
I’ll also go as far as saying you also know that you should see a physio, strengthen glutes with clams and bridges, and get on the foam roller and try dry needling (and maybe even some rocktape/kinesio for the adventurous).
If I’m right- you’ve definitely come to the right place. I’ll describe what we teach our students and new-grad physios at Optimus Health and WHY we treat ITBFS the way we do.
FACT NUMBER 1- PAIN
ITBFS stops people from running due to PAIN.
First, let’s get a GENERAL IDEA about the injury:
What type of pain?
The pain is usually from a combination of inflammatory chemicals that activate pain receptors in a pocket of fluid in the side of the knee (see picture below- titled ‘inflamed and swollen bursa’)
a mechanical force that activates pain receptors by “fraying” or “frictioning” the actual band and the bony part of the femur that it rubs against (almost like a rope rubbing against a rock).
The hard bony part that acts like a rock can be seen below in the side view of the outside of the knee- it’s coloured red in this picture and is called the lateral epicondyle.
Here’s a better pic to show you how the Iliotibial Band (rope) actually crosses aver the lateral epicondyle (Rock) between the patella and the hamstring tendon:
This pic is one of a person standing with their knee straight (in full extension). We’ll talk later about how that changes (and why stairs have such a key impact on this injury).
So, FACT 1- there are two types of pain, CHEMICAL and MECHANICAL.
FACT NUMBER 2- CHEMICAL PAIN
You can STOP THE PAIN by doing two things: Anti-Inflammatories to take away the chemicals that cause pain, and Stop Running to take away the ‘rope friction’ mechanical pain. BOOOOOOOOOO!
One thing that I’ve learnt over the years- NEVER tell a runner to STOP RUNNING! There are so many negative mental and social impacts that it is definitely NOT the 100% correct answer.
I’m a big fan of resting for 4 or 5 days whilst the anti-inflams are doing their job and getting rid of the chemicals, but you shouldn’t STOP completely. I’ll very often just use LOAD MANAGEMENT to reduce the mechanical forces through the ‘rope fray’ ITB by doing a 10 minute run every second day, on a flat surface (NO HILLS) on grass or a running track. I’ll also tell my athletes to avoid stairs (especially going down) and if you have to climb stairs take large steps, 2 or 3 at a time. In thie ‘Rest’ time, it’s definitely worthwhile getting a couple or three sessions of physio/myo to help reduce the mechanical forces on the ITB. So take away the chemical pain with anti-inflams (usually 25mg of Voltaren in the am and pm is enough for 4 days with load management to reduce the chemicals)- make sure you discuss your own medical history and medications with a Qualified Pharmacist before taking any medications!
FACT NUMBER 3- MECHANICAL PAIN
REDUCE THE MECHANICAL PAIN (rope fraying) in order to start running again.
There are two MAIN reasons why the ITB (rope) is pulled tightly over the femoral epicondyle (Rock).
REASON 1- Two key muscles are TOO SHORT (or sometimes described as ‘tight’). The Tensor Fascia Latae (TFL muscle- RED) and the gluteus maximus (GREEN). If these two muscles are too short, the ITB tightens over that femoral condyle. See the pic below to show you how the muscles shorten, and hence why the ITB tightens like a tight rope pulled over a rock (femoral condyle):
REASON 2- When you’re running, if your glutes dont stabilise your pelvis during every single step, you’ll develop something called a Trendelenberg gait pattern. In a basic summary, this running pattern causes the ITB to pull ‘up’ in the same way the short muscles cause it to tighten.
The videos below go into a bit more detail, feel free to skip to FACT NUMBER 4 if you’d like. The first video below shows you the basics of why it is really important to have strong glutes (especially Glute Medius and Minimus)- to avoid that pelvic drop.
The first video (3 min 35 sec) describes a more common and basic weakness pattern using walking or standing to describe it.
The second video (from brilliant running coach James Dunne) will show you in a bit more biomechanical detail about how weak glutes can cause the pelvis to ‘drop’ on the opposite side while running. This drop causes the ITB to pull ‘up’ on the leg that is on the ground during running.
This reduction of MECHANICAL PAIN can be done in two ways:
1- loosen the TFL muscle and glutes- stretching, dry needling, deep tissue massage, foam rolling. If you’d like more info on this I can send you our marathon runners video on lengthening these key muscle groups. *Insert shameless Optimus plug here- Just email me at email@example.com. Best $20 video you’ll ever buy!
PS. Don’t bother rolling the actual ITB- in short, the band is stiffer than concrete and there is no way you will lengthen it with a foam roller any longer than half a percent. You’ll just cause some ridiculous pain and grit your teeth pretending you’re actually doing something worthwhile, all whilst muttering to yourself “no pain, no gain”. Seriously, BOMBOWWWW!!
On the other hand, foam rolling the TFL and Glutes can cause a muscular length change of up to 200%. No more painful ITB rolling people! Target the correct areas! (and don’t get me started on my physics nerdiness, I can go into the details of stress mechanics but I’m sure you just want to get out there and #RehabToRun!)
2- Strengthen your glutes- clams and bridges are a really basic exercise to do this and are probably more suitable for the oldy in the first video above. If you really want to strengthen your glutes for pelvic stability, your best bet is to get a good written program from your physio or strength & conditioning coach/sports therapist to get you deadlifting, arabesque-ing and squatting (once your chemical pain is gone!). Speak to your Sports physio about this!
FACT NUMBER 4
Strengthening and loosening and medicating will only work if you do it in the CORRECT ORDER and TIMING!
It’s really important to stop the chemical pain first. Reduce your running and squatting load during this time.
Loosening can take anywhere from one physio session with lots of deep tissue work, needling and a very good stretching session, to a few weeks of consistent hard rehab work.
Strengthening can take anywhere from a few days-to-weeks (technique and activation for other therapists reading this) to a period of 6-to-8 weeks (hypertrophy of the muscles for the other therapists).
Timing of these phases is super important and if you need any help, see your Sports Physio!
FACT NUMBER 5
Core stability exercises will help reduce your pelvic ‘drops’ like the girl in yellow in the video above. Pilates and Yoga are great cross-training activities for runners.
I’ll finish up on a really positive note- ITB Friction Syndrome doesn’t have to stop you completely. Just make sure that the sharp shooting stabby pain (chemical) is settled before doing any simple 10 minute runs. This can take as little as two days.
WHO SAID RUNNERS HAVE TO BE PATIENT?!
Hope you enjoyed the reading! Send me emails about any other running or sport injuries you’d like me to blog on! firstname.lastname@example.org