The London marathon is such a popular event with amateur and charity runners of all shapes, sizes and ages running alongside (or a few miles behind!) the professionals. The challenge of pushing your body around 26.2 miles is not something to take on lightly and when you are performing a repetitive impact motion like running over that distance, small variations in your form, running style and equipment can make a big difference to the loading of your joints and tendons. The knee is one of the zones which has to withstand the most force and knee pain is therefore not surprisingly the most frequent complaint we see in the physiotherapy clinic once runners start increasing their mileage. Iliotibial band (friction) syndrome (ITBS) is one specific and common diagnosis associated with distance running.
Causes of Iliotibial Band ‘Friction’ Syndrome (ITBFS)
The Iliotibial band (or ITB) is a band of fascia (dense fibrous tissue) which attaches from the front of the pelvis bone (the ilium) to the side of the knee joint (the tibia). It runs down the outside of the thigh and can feel quite tight or ‘lumpy’ particularly in runners. When the knee bends the band moves behind a prominence on the outside of the knee joint (the femoral condyle). The exact mechanism by which the ‘friction’ occurs is not fully understood but it is believed that a bursa (sac of synovial fluid) lies between the ITB and the condyle here becomes irritated in ITBS causing an inflammatory reaction and pain. The contact is highest when the knee is bent at 20-30degrees just after foot strike. Running downhill is associated more with smaller angles of knee flexion (bending) making friction more likely to occur, whereas sprinting and faster running usually have greater angles of knee bending just after foot strike and are less likely to cause friction.
The likelihood of friction occurring is greater if there is more tension in the band itself. This is influenced by the action of gluteus maximus and tensor fascia lata (a hip flexor muscle), which insert into the band at the hip. An imbalance in these muscle groups can lead to greater tension in the ITB.
The position of the foot when it strikes the ground and as the knee is bending is another significant factor in ITBS. The majority of long distance amateur runners are heel strikers. The normal pattern for a heel striker is to strike the ground with the outside of the foot and quickly roll onto the inside in order to push off with the big toe. This rotation movement is known as pronation. If a runner has a very stiff foot which doesn’t ‘pronate’ during loading it can lead to greater loading and tension of the structures in the outside of the thigh-particularly the lateral calf and ITB. On the other hand ‘excessive ‘or ‘over pronation’ of the foot stretches the ITB into a more internally rotated position for push off, also increasing the risk of friction.
Weakness in the core muscles, which support the trunk and pelvis during running, can also create problems. A lack of stability centrally can mean increased pelvic rotation which is also linked to increased tension in the ITB.
Pain from ITB friction syndrome is usually felt on the outside of the knee and there is often a tender spot which can be palpated in this region. It is not associated with visible swelling but there is sometimes a small amount of fluid found here on ultrasound examination.
It is common for the pain to arise after a runner achieves a certain mileage. The pain can limit the ability to run in some cases, whereas others are able to continue running through the discomfort but experience more pain after they finish or the following day, particularly with activities like walking downstairs.
- To run or not to run?
The first thing your physiotherapist will try to establish is whether you should continue running or if it is better to take a break. This is often based on the severity of you symptoms, which is gauged by how quickly they come on during a run and how long they last for afterwards. For example if they do not arise until after 10miles, it may be possible to continue training with shorter runs, even some sprint training (less likely to increase ITB friction due to the knee angle –see above) whilst you work on the factors which are causing problems in the longer runs. Fatigue is a big factor on longer runs and if you have weaknesses or imbalances in hip and core muscles these may become more apparent the longer you run.
It is important that your physiotherapist looks at your style of running and your form during push off and landing phases. This helps to determine why your ITB is getting overstretched or overloaded. This is often best done with a video camera on a treadmill. Functional exercises such as squats, lunges and hopping often highlight imbalances in your core and hip muscles as well as over or under pronation at the foot.
Your physiotherapist will check your trainers to make sure they are not too worn and that they appropriate for your foot type, providing adequate shock absorption or pronation control where necessary. If there is enough time before the an event like the marathon, your physiotherapist might recommend that you look to change your trainers to help promote a better foot positions when running. Shops such as Runners Need are very helpful when selecting trainers as their staff are trained to recognise foot types and recommend appropriate footwear.
Some runners continue to overpronate even in the right type of footwear. If this is felt to be the driving force behind the problem at the knee, your physiotherapist may recommend you try over the counter insoles or refer you to a podiatrist for custom made orthotics. These can be a good investment if you are planning on doing a lot of running. Exercises to improve your balance and control of foot rotation may also be given.
- Strengthening Exercises
ITBS is commonly associated with weakness of the gluteal muscles, particularly the gluteus medius muscle which helps to control pelvic rotation when you land on one leg. Below are some examples of strengthening exercises.
1. Clam –in side-lying, with both knees bent at 45degress, keeping the heels together, lift the top knee, taking care not to rotate in the pelvis. Repeat x20
2. Bridging-lying on your back with your legs bent up and feet flat, bridge up slowly, pealing your spine off the floor until you are resting on your shoulder blades. Hold this position and lift one leg up, without tilting or twisting in your pelvis, repeat for each leg, then roll your spine down again and repeat the exercise x 5.
3. Isometric wall exercise-stand with the unaffected leg next to a wall, the hip and knee flexed at 90degrees, weight on the affected leg. Push into the wall with the hip of the unaffected leg, hold for 5 seconds, relax and repeat x 10. You should feel this activating the muscle behind the hip on your affected leg (this is gluteus medius).
- Stretching and Massage
Stretching the ITB is not easy because it is not a muscle in itself. You can stretch the gluteals and the tensor fascia lata (hip flexor), which attach into it, if they are found to be restricted. Your physiotherapist will also check for inflexibility in other muscles such as the calf, hamstrings and quadriceps. Inflexibilities in these areas can be associated with changes in foot and knee rotation during running.
Massage, myofascial release and acupuncture can be very effective in restoring some flexibility in the ITB itself. It can help to give relief of symptoms, although it can be very painful during treatment.
Your physiotherapist may recommend you get a foam roller to do some massage on the ITB yourself. You can find pictures of this exercise online or videos on U-tube.
- Running Technique
Your physiotherapist may be able to advise you on some tips for your running style, which can help to affect the loading of the ITB. Changing your stride length or the number of steps you are taking can alter the knee angle slightly causing less friction to the ITB. Forefoot running has recently become more popular and there is research that indicates this is less likely to create friction of the ITB. However this running technique cannot be learned overnight and a gradual approach, which allows the body to adapt to this very different loading pattern, is needed.
Kinesiotaping techniques can be used to reduce tension in the ITB, enabling runners to go further before they reach the point of friction. Your physiotherapist can show you the best way to tape the ITB before your run. This can be very useful if you have an imminent event you really want to participate in.
- Ice etc…
Putting ice onto the area after running can help to combat an inflammatory reaction and relieve symptoms. In more severe cases, where there is a persistent inflammatory reaction, your physiotherapist may recommend you to a sports physician. They may conduct an ultrasound scan to look at the outside of the knee, If fluid is found in the bursa space here, they may recommend a course of non-steroidal anti-inflammatory medication or a local steroid injection to get rid of inflammatory cells. However even In these cases the factors discussed earlier still need to be addressed in order to prevent the friction occurring again when you return to running.
- Stay Positive!
This can be a frustrating condition, but stay positive. Studies indicate that the majority of sufferers are able to get back to running eventually with conservative management taking into account all the factors discussed here.
By Nikki Richards MPHTY(Sports) BSc(hons) Physio MCSPReferencesBeals and Flanigan (2013) A review of treatments for Iliotibial Band Syndrome in the Athletic Population. Journal of Sports Medicine, Vol 2013, Article ID 36719.