Iliotibial Band Syndrome

This month we are discussing the second most common knee injury in running, iliotibial band syndrome. ITBS shares some common causes with patellofemoral pain syndrome, and requires a similar approach to treatment. However, while the pain of PFPS can be sometimes be "run through" during treatment, doing so with ITBS will prolong treatment and recovery time. In fact, the severity of the pain will often prevent any running at all.

I have had this injury myself and have treated many bewildered runners who have been confused by this injury. To understand this injury, it is first necessary to know the anatomy and function of the iliotibial band. It does have a purpose besides causing agony and frustration in many runners. The band is actually a tract of ligament-like connective tissue. It runs from two muscles, the tensor fascia latae on the outer hip and gluteus maximus on the buttocks, along the outer thigh, and attaches at the outer patella and tibia at the knee. It lies between the hamstrings and quadriceps along this path, and allows all of these muscles to stabilize the outer hip and knee.

Distance running requires a great deal of force to be absorbed while moving forward from one leg to the other. Much of the stability required to do this comes from the outer hip, thigh, knee, and calf muscles. They work to control the standing thigh’s inward movement and to prevent the pelvis from dropping to the opposite, non weight-bearing side. Problems occur when any of those muscles, and the iliotibial band, becomes fatigued and tight. Once they do so, pain can occur in two ways. One is from the tightened band now not having enough length to allow proper knee flexion, leading to painful rubbing (friction) of the band at its insertion at the knee (and less commonly, at the hip). The other is from trigger points (knots) and adhesions forming in the muscles and band and referring pain to the outer knee and even the lower leg.

Unfortunately, the symptoms of tightness are often either not noticed or are ignored. In the typical scenario, pain will then develop along the outside of the knee, the outer hip and/or the thigh, during running. It may be a mild ache at first, but with further running and more tightening will be sharper and may force you to stop running. Often there is a specific time in your run where running is no longer possible- the knee feels as it is being squeezed in a vice, and must be kept straight to avoid the burning pain. At this point, many think they have a stress fracture or torn ligament/cartilage. But the strange thing about ITBS is that once you stop running, the pain often miraculously disappears within minutes, especially in early stages, and you can walk pain-free! That is why people often try to run again only to have the process repeat itself. With further progression, however, bending the knee will remain very painful for at least 24 hours after a run, and if you haven’t sought treatment yet, you now will.

Acute treatment depends on how far the injury has progressed. If you cannot bend the knee, stopping running and applying ice to the tendon by the knee is the first step. If there is significant swelling at the knee, office treatment with electrical stimulation and ultrasound may be necessary. At any stage, stretching of the outer hip and thigh must begin immediately, along with manual Active Release Technique of the tightened fibers and adhesisons. Patients often have significant relief of pain and increased range of motion with two to three of these specific soft-tissue treatments. Activities that usually can be tolerated include swimming and possibly light cycling, however cycling easy may still irritate. Sports that don’t require repetitive knee flexion and extension, such as tennis, may be tolerated before running can.

Full treatment involves addressing why the band, hip and thigh muscles lose their proper length- the causative factors. I often see patients who have had previous treatment without relief because only the knee was addressed. The entire lower extremity from the lower back to the foot must be checked. Training errors may include excessive downhill running, always running on a cambered road (outer leg) in the same direction (Central Park!), rapid increase in mileage or long run length, and racing too often. Mechanical faults may include tightness of the calf, hip flexor and hip adductor muscles, and weakness of the hip abductors. Other factors may include a wider than normal band, bow-legs, and underpronation or overpronation. All of these factors may make it more difficult for the band tissues to remain relaxed during the repetitive motion of running. Once the acute pain has subsided, continuing treatments include adding strengthening exercises(see below), continued stretching, further muscle treatments, spinal and hip adjustments for proper pelvic motion, orthotics if necessary, and correcting training errors. When the exercises can be performed pain-free resuming running can begin. Start with 100 yard strides at first, building to continuous running of 10 minutes and then adding time in 5 minute increments. Once you can run 45 minutes pain-free, regular training can resume. If the above factors are addressed re-injury is unlikely, but if tightness returns treatment should start then, before pain returns.

Hip Abductor (Gluteus Medius) strengthening:

1) lie on the unaffected side, with your bottom leg bent at the knee and the injured leg straight and lying on top of the bottom leg. Raise the injured leg, with the knee straight, to 30 degrees upwards, pause for one second, lower and repeat. Do not bring the thigh forward as the leg rises, and do not use your lower back muscles to raise the hip. Work up to repeating up to 20 times for two sets. When this is pain-free, the next exercise, done standing, can begin.

2) Standing, raise the uninjured leg with the knee bent. Without bending the knee of the injured leg, let your pelvis drop towards the uninjured side and then raise it by contracting the outer hip muscle (gluteus medius) on the standing, injured side. This is a small motion, but will fatigue a weak gluteus medius muscle by 10 to 15 repetitions. Again, work up to two sets of 20 repetitions.

This article is for informational purposes only and should not be used for personal advice or diagnosis without first consulting a health-care professional. If you have, or suspect you have an health-care problem, then you should immediately contact a qualified health-care professional for treatment.

Healing your heel: Dealing with "Plantar Fasciitis"

One of the more frustrating running injuries that can occur is "plantar fasciitis". If not addressed properly it can severely limit your training and racing plans, but with early recognition and proper treatment healing time is reduced, providing a quicker return to full function. The plantar fascia is a strong band of connective tissue that runs on the bottom of the foot, from the forefoot back to its insertion on the heel bone (the calcaneus). It supports the arch, and covers a group of small, strong muscles and tendons that also support the arch and bend the toes.

Problems arise here because there is a very high tension on the fascia at its insertion point when the foot "toes off" during the propulsive phase of running, as it becomes taut to provide stability for the foot to propel us forward. With repetitive use, tightness, irritation and then painful micro tears of the fascia fibers at the insertion point can occur. Besides this susceptible spot, the fascia also can be irritated and tighten further down in the middle of arch. In some cases both areas are involved. In either case, scar tissue starts to form in the fascia as the body attempts to compensate for the stress being placed on the tissue. Scar tissue is not as flexible as healthy tissue, and makes the area even more prone to injury.

The propulsion mechanism described above can become overstressed by several factors. Overpronation or a flat arch can prolong the propulsive phase, stressing the fascia at its insertion point. A high arch can also add tension at either the insertion, or the middle part, of the fascia. Tightness of the achilles tendon, calf and hamstring muscles can cause a compensatory increase in arch tension, as well as increased pronation, setting the process in motion. Also, tightness of the arch muscles can tighten the fascia or cause pain similar to that of fasciitis. Being overweight is a risk factor, and often beginner runners who are running for weight loss get this injury. Not enough recovery time between workouts, a rapid increase in mileage, and running in worn-out or poorly fitting shoes are training errors that can be involved.

First symptoms usually are felt either at the end of a run, as an aching or sharp pain at the inner heel or midfoot, or upon weight-bearing first thing in the morning, usually at the heel. The athlete will find relief by keeping weight on the outer heel, to avoid toeing-off and stretching the irritated fascia. With further development, pain will start to be felt early in a run, then disappear with warm up, and will also be present after periods of inactivity. If not treated at this stage, eventually running form will be altered, and then running will become very painful until not possible, as will be walking. Treatment, or at least assessment of what the problem is, should begin at the first stage.

Before a diagnosis of a plantar fascia/arch muscle problem can be made, other, less common, conditions such as stress fracture of the calcaneus and heel pad syndrome must be ruled out. The heel pad is a fatty tissue that adds cushioning to the heel, and can become thinned out (atrophy) in some individuals. With these there is avoidance of any heel contact, unlike with fascitis, where toe-off is worse. Heel spurs, which are a growth of bone off of the calcaneus at the fascia attachment point, may develop as a result of the fascia injury, but will not cause pain unless very large. Also, sciatic pains from the lower back or hip are sometimes first felt at the heel or foot, and local nerve entrapment can occur.

For acute pain, treatment should start with ice massage, which can help decrease any inflammation or swelling, and heel cushions, which can reduce contact pain when walking (put in both shoes to keep equal leg-lengths). Self-massage of the tight fascia, and arch or calf muscles can help. The arch can be done by rolling the foot on a golf ball for 20-60 seconds, especially first thing in the morning before getting out of bed, as the fascia usually shortens overnight. Stretching of the achilles and calf can be performed seated on the floor by using a towel to gently pull your foot towards you. Keeping your foot turned in slightly (supination) will reduce tension on the plantar fascia.

Office treatment of acute or chronic cases will involve using Active Release Technique to "free-up" the tightened fascia before serious scar tissue forms. The arch and calf muscles and any other muscle imbalances or joint restrictions must be treated. Electric stimulation and/or ultrasound can be used in the acute stage, to decrease pain and swelling. Stubborn cases may require use of a night splint, which keeps the fascia from tightening overnight and allows healing of the fibers. Finally, orthotics can stabilize an overpronating foot and relieve the pressure on the fascia’s insertion point, correcting the cause of the problem in some cases.

Once the acute stage is over, specific strengthening and stretching exercises should be undertaken. The muscles that are often weak are the ankle dorsiflexors and toe extensors. The calf and hamstrings should be stretched more often if tight, as calf tightness is a major cause of this injury, and balance and plyometric exercises can help.

Before returning to run, you must have no pain on the "hop test", involving a small jump on the injured leg from a standing position. Running can continue as long as the symptoms are not worse and the arch feels looser during running and in the morning. However, mileage should be cut back at least 25 percent, and if pain persists seek professional treatment as discussed above. Besides ruling out other injuries, using Active Release Technique can often heal the fascia in just a few visits in the early stages. Again, ignoring the early symptoms with this injury will often lead to a chronic problem, with possibly months of recovery needed.

This article should be used for informational purposes only, and should not be used as personal advice or diagnosis without first consulting a health-care professional. If you have, or suspect you have, a health-care problem, then you should immediately contact a qualified health-care professional for treatment.

Answering the Knee Question

One major myth about distance running is that it will "ruin your knees". Many non-runners often wonder how the knees can withstand a marathon. Many of us have heard the question from a non-runner: "Don’t your knees hurt you after all that running?" This can be as annoying a question as "so how many miles was that marathon you did?" The good news is that unless you have had a significant previous joint injury, such as torn ligaments or cartilage, there is no evidence that beginning and continuing distance running will cause osteoarthritis or other traumatic injury. While the knee is the most frequently injured area in running, most of the injuries are of the overuse nature, and can be managed with correct treatment.

The knee is actually composed of two joints. One is the patellofemoral, between the kneecap (patella) and femur (thighbone), and the other is between the tibia (shinbone) and femur. Also nearby is the joint between the tibia and fibula (outer leg bone.) The patella attaches the quadriceps to the lower leg through the patella tendon. The knee joint lies between the foot and the hip/pelvis, and its status is dependent on proper alignment in those joints, which is one reason it is so frequently the site of pain. Thus the approach to keeping our knees healthy must include looking above and below the knee itself.

The two most common overuse injuries at the knee have been named patellofemoral/malalignment syndrome and iliotibial band syndrome, and they share some common causes and treatments. Patellar tendinitis is a related problem. Iliotibial band syndrome will be discussed next month.

Patellofemoral alignment syndrome usually involves pain at the front of the knee, around the kneecap, which may be from pain sensitive muscle (the quadriceps), tendon or both. Symptoms usually start with a dull ache either early or late in a run. Hill training may exacerbate. Besides running, pain may be felt going up or down stairs and after sitting. "Movie sign" is present when you feel more pain after sitting (as at the movies) and then straighten your legs to walk. Also, a "clicking" feeling may be present when flexing and extending your leg.

Irritation to the knee tissues occurs when the patella does not glide, or "track", properly along the femur as the knee flexes and extends (which may produce the clicking feeling). Tenderness is usually found where the muscle or tendon insert on the patella. As in all running injuries, a combination of extrinsic (training/equipment/technique) and intrinsic (structural/biomechanical) factors is causative, and all must be addressed. Intrinsically, both muscle imbalance and joint alignment can be to blame. The patella can be pulled laterally (outward) by a tight outer quadriceps overpowering a weaker inner quadriceps. Overuse causes adhesions and trigger points (knots) to form in the muscles, which can refer pain to the kneecap as well as put abnormal tension on the tendon. Restriction of motion in the lower back or hips, along with tight hamstrings and calf muscles can also put more pressure on the kneecap. The angle at which the femur and tibia meet, called the "Q-angle", can predispose to tracking problems if it is greater than normal. Many women have knee problems as their pelvis is shaped wider and creates a larger q-angle. Finally, an ankle and arch that overpronate (flatten too much upon wieghtbearing) can also cause abnormal tracking, as the lower leg and knee follow the foot inward.

Extrinsically, running on cambered roads will put the inner leg at risk, as the knee will be forced inward. Other extrinsic factors include a rapid increase in daily or total mileage and too much hill training.

Treatment must involve addressing both the acute pain, if present, and the underlying causes of either acute or chronic pain. Acute care includes ice, compression, and elevation to decrease any swelling and maintain as much range of motion as possible, as well as electric muscle stimulation for the same purpose. Isometric quadriceps exercises can begin almost immediately to improve strength of the inner quadriceps (vastus medialis).

Treatment must involve addressing both the acute pain, if present, and the underlying causes of either acute or chronic pain. Acute care includes ice, compression, and elevation to decrease any swelling and maintain as much range of motion as possible, as well as electric muscle stimulation for the same purpose. Isometric quadriceps exercises can begin almost immediately to improve strength of the inner quadriceps (vastus medialis).

Taping of the patella can help guide it back into a more pain-free position, support the involved muscles, and also relieve tension on the tendon if it is involved.

As with all overuse injuries, once the acute pain/swelling is controlled the biomechanical factors and any training errors can be addressed. The tight muscles mentioned above must be stretched. Office treatment with Active Release Technique(ART) of the involved soft-tissues is often a necessity, to relieve the pain-causing adhesions, trigger points and tightness, as well as spinal, hip and knee adjustments to restore proper joint motion. Next, the weak muscles must be strengthened. Straight leg raises are first added to the isometrics, and then exercises involving knee flexion can be added. These are the short-arc extensions, quarter squats, and step-ups. Elastic tubing or bands can provide additional resistance to the short-arcs and squats. A gradual return to running can start once these exercises can be performed pain-free, however orthotics may be needed to control overpronation.

To prevent re-occurrence, as well as to prevent first-time occurrence, all of the above exercises and treatments can be employed. This will ensure you don’t have to answer the knee question with "of course my knees hurt, I just ran 26.2 miles…"

This article is for informational purposes only, and should not be used as personal advice or diagnosis without first consulting a health-care professional. If you have, or suspect you have a health-care problem, then you should immediately contact a qualified health-care professional for treatment.