Why Do I Get Knee Pain While Running?
Getting pain in your knee while running is a surprisingly common complaint. If you are experiencing this, you are not alone. Many people are even fearful of running because getting hurt while doing it is such a frequent complaint, with as many as 30-70% (depending upon how you measure it) of runners are injured every year.
A knee injury can be maddening, to say the least, often laying waste to months of training and not only causing you to miss the event, but the recovery period may also lead to loss of hard-won strength and conditioning. The problems often don’t end there, because knee injuries have an unfortunate tendency to recur again, just when you think you’ve finally got on top of it.
While there are several possible reasons you could be experiencing pain, there are two conditions which are most common; Iliotibial band syndrome (ITBS) and Patellofemoral pain syndrome. Out of these two the one that most commonly plagues runners, hikers and cyclists is ITBS.
ITBS is responsible for up to 1 in 20 lower limb injuries in runners, and up to a quarter of all long-distance runners eventually, become afflicted with the condition.1 You may even get this condition through any vigorous physical training regime.2
Between 30 to 70% of runners are injured each year. One of the most common injuries is runners knee, also known as Iliotibial Band SyndromeClick To Tweet
Do I have Iliotibial Band Syndrome?
ITBS is pain that typically starts out of the blue while running, and often progresses very quickly from mild pain to a deep dull ache in the side of the knee joint. Commonly the pain begins during an unusually long run, typically when going down a hill.
Patellofemoral pain is typically pain on the front of the knee, under the kneecap, often more caused by running up hills.
The location of the pain is often the critical determining factor as to which condition you have.
If you have hip pain, buttock pain or thigh pain but no knee pain then you do not have runners knee. You have a lower back, pelvis or hip problem. The exact cause could be anything from a simple muscular trigger point with referred pain, to a sacroiliac joint syndrome, facet joint and nerve root referral from the lower back (to name just a few possibilities).
If you are unsure as to what is causing your pain and it is persisting despite your best efforts to self-treat or rest it, then please seek the advice of a qualified medical professional and get an accurate diagnosis.
What does Iliotibial Band Syndrome feel like?
The most distinguishing feature of ITBS is a pain just to the side (lateral) of the knee that is worse after running or walking downhill. Some other signs are also worth knowing:
- The epicentre of the pain is precisely on the side of the knee joint. You may have pain anywhere else in the knee at the same time, but the side is the sharpest and most severe pain point.
- ITBS is a repetitive strain type injury that happens typically after an uncharacteristically long or difficult workout, such as a long hike through the mountains, or a long run up and down hills, mainly downhill, once you are already tired.
- ITBS pain usually begins quite quickly, progressing to its full strength within a few minutes to an hour or so, but the severe pain does not begin immediately, as it would in a traumatic sprain/strain injury.
- ITBS pain often feels fine while you are resting, yet the pain frustratingly flares up when you walk, run or cycle beyond a certain distance. For some unfortunate people, the pain can be chronic and all the time, but this is quite unusual.
What Causes Iliotibial Band Syndrome?
The short answer is no one knows for sure. ITBS is one of the mysterious chronic pain, overuse syndromes that has so far divided scientific opinion and failed to be solved in a predictable, repeatable manner so far.
Like most chronic pain conditions the cause is usually multifactorial and highly individual. Thankfully there is research that we can lean on to both debunk some of the conventionally accepted treatments and also make some more sound conclusions on how to both treat and avoid this frustrating and puzzling condition.
What Is The Best Treatment For ITBS?
“Rest is by far and away the most important treatment strategy for iliotibial band syndrome”
Most minor cases of ITBS resolve following a period of rest for 1-4 weeks, and that will hopefully be the last of it. More stubborn, severe cases may need as much as 3-6 months of proper rest, as well as individualised treatment to correct, which is where the problems begin.
Many athletes find it nearly impossible to rest sufficiently for stubborn cases of ITBS to heal correctly. Endurance athletes are perhaps the worst, and runners are at the top of that pile. Preferring to push through the pain or continue to train, at a reduced rate, the irritated ITB never stands a chance.
If you are suffering from runner’s knee, it is essential to make sure that you have adequately healed before you step up your training again. ITBS a nasty tendency to recur, even after many months of feeling better, once you step up the miles again. Not only can this be very demotivating, but recurrent episodes of runner’s knee can significantly set you back in your hard-won conditioning.
In the sections below I will outline the best treatment options available, but hands down, the best advice is to rest and to rest well. Before that, let’s look at some of the common myths surrounding this condition.
The Most Common Myth Surrounding Runner’s Knee
There are many misconceptions around exactly how the ITB insertion point on the knee becomes injured and painful. Perhaps the most significant one, which leads to mismanagement and failed treatments is that the ITB itself becomes too tight, which means that treatment should focus upon lengthening it with stretching, foam rolling or deep tissue massage.
Another common is to assume that taking ibuprofen or other NSAIDs to lower the inflammation will fix the problem (more about this later).
Much of the difficulty in treating this condition stems from the misunderstanding, even among sports doctors, as to what exactly has gone wrong in the knee for it to become so painful.
The prevailing theory is that the ITB becomes shortened and the tendinous attachment site at the lateral epicondyle of the knee gets inflamed by repeatedly flicking over this condyle. However, as I will discuss below, the ITB itself cannot become shortened, there is no tendinitis (inflammation) occurring in most cases, and it is doubtful that there is any ‘flicking’ of the ITB over the lateral epicondyle to cause friction or inflammation. Indeed, ITBS is often called iliotibial band friction syndrome, but there is very likely to be no friction occurring at all.
What Exactly Is The Iliotibial Band (ITB)?
The ITB is a thick band of fascia, often described as a tendon that runs from the anterolateral iliac tubercle portion of the external lip of the iliac crest and inserts at the lateral condyle of the tibia at Gerdy’s tubercle.
The ITB is also known as the iliotibial tract because it is an extension and reinforcement of the fascia lata, which is the deep fascia of the thigh that surrounds the muscles and forms the outer limits of the thigh. The ITB is a lateral thickening of this deeper fascia, and it anchors to the lateral femur, or thigh bone, throughout its length.
The ITB connects to the capsule surrounding the knee joint, so that when it comes under increased tension, like when the tensor fascial late muscle contracts, the knee joint is pulled tight and braced, which may importantly keep the joint stable and protected when running.
Interestingly, the ITB has also been found anatomically to connect to the hip joint capsule, underneath the tensor fascia later muscle. These deep connections of the ITB ligament mean that it not free to move around like other tendons, and is anchored firmly in place. This little fact has great significance when it comes to designing an effective treatment strategy and adds serious doubt to the effectiveness of the most common approaches that attempt to stretch and lengthen the ITB.
There are many ‘odd’ anatomical quirks to the ITB, like the fact that technically it is a ligament, rather than a tendon since is connects bone to bone (along the entire length of the femur), rather than muscle to bone as a tendon would.
Most tendons are significantly smaller than the muscles they attach to, but in the case of the ITB, it is much longer than the tensor fascia data muscle that sits on its upper end. The Gluteus maximus does also attach to the ITB and technically use it as a tendon; however, its job is probably to pull the band tight and stabilise the knee and hip joint, rather than to move those joints.
One of the fascinating attributes of the ITB is that it has been found to function as an energy storage device during gait in a similar but less significant way than the Achilles tendon. It gets loaded up during your stride only to release energy later in the stride to give you a mechanical boost.3
Does The ITB flick over the knee bone?
We’ve just taken a close look at the anatomy of the ITB and learned that it is deeply anchored into place, and that should mean that it’s unlikely to move, or indeed “flick’ over the side of the knee leading to a friction type tendonitis syndrome.
in 2006 Fairclough et al. carried out a study on symptomatic athletes, asymptomatic volunteers and cadavers (dead bodies), using surface anatomy and MRIs they concluded the following:4
“The ITB is prevented from rolling over the epicondyle by its femoral anchorage and because it is a part of the fascia lata. We suggest that it creates the illusion of movement, because of changing tension in its anterior and posterior fibres during knee flexion.”
A study in 2013, by jesting et al., later contradicted this finding. They used ultrasound to confirm that they could detect movement of the ITB during knee flexion, on a group of 20 symptomatic runners.5
“Our results indicate that the ITB does in fact move relative to the femur during the functional ranges of knee motion.”
This raises an interesting problem with placing too much emphasis on any single piece of science. In my mind, the most likely explanation here is that there is anatomical variance. Perhaps some people have an ITB that less securely anchors to the femur via the fascia lata than others. Anatomical variance is well known to be a genuine phenomenon, with people even able to have vastly different positioning, shape and size of organs such as the stomach and appendix.
More research is needed to prove either way if the ITB moves or remains still during gait.
So, the ITB may move in some cases but what is going on beneath the surface to cause all of that pain?
Where Does The Pain Come From In Runners Knee?
The paper by Fairclough et al. gives us the most useful insight into what is going on beneath the surface. They argue that the iliotibial band itself is not the structure that gets irritated in runners knee.
This goes against conventional wisdom which suggests that the pain due to inflammation of the tendon as it inserts into the knee.
Their MRI studies, as well as other surgical studies, have revealed that there may not even be a bursa under the ITB that could get inflamed. Instead, there is a presence of fat deep to the ITB in the region of the fibrous attachments to the femur. This deep layer of fat is present around many tendons in the body and is thought to play a role in proprioception (neurological feedback to your brain). Another possibility is that there is a lateral recess of the knee joint in that space which could look like a bursa (lateral synovial recess). The truth is that no one knows for sure, again there could be anatomical variance confusing the picture.
Interestingly a group of surgeons in Brussels recently carried out a new form of ITBS surgery with great success. Rather than merely loosening the ITB as previous surgical techniques had done, they decided to scrape out the tissue that sits beneath the tendon and the femur, in the so-called lateral synovial recess. They had excellent success, with 32 or the 36 athletes having good to excellent results and all being able to get back to running after 3 months.6
While this is only one study, it does provide weight to the theory that it is what sits between the tendon and the knee that causes the pain, rather than the tendon attachment itself.
Iliotibial Band Syndrome Is An Overuse Injury.
Many myths are surrounding ITBS and its causes, but one of the major ones is the inflammation myth. There are several treatments, such as the prescription of ibuprofen and corticosteroid injections which fail to help the patient long-term because of it.
So we need to understand what is going on with these irritated tissues. Recent science has shown that chronic overuse repetitive strain type injuries, which ITBS is an example of, involve very different biochemistry to that of an acute injury, infection or trauma.7
When you experience an acute injury, such as a trauma or sprain, there is a classic inflammatory response set off. If you study the injured tissue, you will find evidence of immune system activation and the presence of white blood cells. This does not happen with chronic repetitive strain type injuries. Instead, you find evidence of collagen degeneration and tendon degeneration.8
This is so important to understand when it comes to ITBS, because the condition is very commonly misunderstood to be one of out of control inflammation.
A common treatment option offered is corticosteroid injections into the site of the pain at the side of the knee. These are powerful drugs and can produce a significant to complete resolution of the pain, but most often this is temporary with the pain returning at a later date. The process is not without consequence, however, since the steroid hormones further degrade the integrity of the local tissues. Since ITBS was already a degenerative process, the use of corticosteroid injections may worsen the condition and speed up its decline, long-term.9
A Brief Warning On Ibuprofen
Ibuprofen is one of the non-steroidal anti-inflammatory (NSAID) drugs that tend to be eaten like sweets and widely assumed to perfectly safe. Yet there is a growing body of evidence to show that they can cause significant harm to your digestive lining and some NSAIDs like Diclofenac have alarmingly been shown to increase your risk of stroke.10
Another very important risk to understand about NSAIDs is that they have been shown to impair soft tissue healing – not what you want when you are trying to heal from a degenerative overuse injury like ITBS.
Funnily enough, there is no evidence to show that NSAIDs help with ITBS, but there is evidence to show that they don’t. Again, this makes sense when we consider that the tissue damage is due to overuse degeneration, rather than inflammation.11
There are other risks associated with NSAIDs, you can read all about them here.
The Relationship Between Your Spine, Pelvis, Hip And Foot And Runners Knee?
Unfortunately, at this point, due to a lack of research, we cannot wholly rely upon research studies to explain the way forwards.
There have been studies showing that pronation (feet that roll inwards) leads to a higher incidence of ITBS 12
Yet at the same time, other studies have shown that reduced pronation was a more common factor in the development of ITBS.13,14
We can, however, rely upon common sense. Since ITBS most commonly affects people on one side of their body, it cannot be purely a spontaneous condition that develops in around 25% of athletes who overdo it in a race. Otherwise, logic would dictate that both knees may suffer equally.
There must be direct biomechanical and neurological reasons for why one ITB finds itself in a painful degenerative state whereas the other does not.
After 12 years in clinical practice, it has become clear that there is a set pattern for which human biomechanics “go wrong”. This pattern is a torquing pattern, and it is analogous to the twisting of a tea towel or a rubber band. The more that you twist the structure, the more that it tightens and the more that the biomechanics become asymmetrical. This anatomical asymmetry likely has a big part to play in the development of ITBS (authors opinion).
Typically, when I assess a patient with knee pain, back pain, hip pain, foot pain, really any pain that is chronic, there is a visible twist through the structure. This shows up and a rotation in the pelvis (also clearly visible on x-rays), one side internal tibial rotation (knee that turns in) and pronation (a foot that turns in). In sacro-occipital technique (a common technique widely practised by chiropractors around the world) this is called a category two posture.
A category two posture results in mechanical pelvic, knee and foot stress down one side. Commonly you the development of overuse injuries like ITBS, will be found on that side because it is less able to adapt to the ground reactive force as you run.15
Dr George Goodheart, founder of applied kinesiology further developed the understanding of the category 2 posture by assessing the functional strength of the muscles involved. Upon examination typically we find a weakness of the tibialis posterior (a key muscle that prevents foot over-pronation), the gastrocnemius and souls muscle (key muscles for generating power when running) and the sartorius and gracious muscles (muscles that stabilise the inside of the knee and hold the prevent the pelvis from tilting posterior.) These findings will be verified by any AK practitioner with experience.
An interesting correlation with these essential muscles is that they have all been observed to become neurologically inhibited under excessive physiological stress since they appear to be affected particularly by the adrenal glands and the stress response. This may be one of the reasons that athletes usually get ITBS after a long run, typically following 90 minutes or more of exercise. Physiologically there is a higher demand placed upon anaerobic system at this point as glucose levels drop, and if they aren’t replenished with a sports gel or drink, cortisol may be released to break down glycogen stores and free up more glucose.
That, however, is a proposed theory, at this point lacking any hard science to back it up but something I have seen correlated in clinical practice. Part of the treatment in these cases may be to work on structural alignment using chiropractic structural correction methods, as well as working on healing any injured muscles of the knee, pelvis and foot. Long-term success may require the adoption of more stringent rest and renewal strategies, as well as a deliberate attempt to reduce the athlete’s lifestyle stress load, diet and training regimen since overtraining is often an issue.
Does Poor Running Technique Or Using The Wrong Trainers Cause Runners Knee?
There are two schools of thought here. The first is that you are born to run. We are all, underneath the veil of whatever biomechanical imbalances we may have acquired, athletes. Humans are incredible endurance machines, perhaps the most gifted endurance animal of them all.
There is some interesting anthropological evidence to suggest that we evolved a pack hunting animals, running after animals for up to days on end until they eventually exhausted themselves from dehydration or overheating, at which point we would catch and kill the prize. This theory makes much sense to me; the human frame has adapted and is biomechanically perfect for running. Anatomically we are very well suited to it.
For that reason, I am always loathed to hear someone describe themselves as a not being a natural runner, or unsuited to running because they have gotten injured a few times.
The other way to look at it is through the lens of truth which reveals that many of us have become deconditioned through years of sedentary living. Our muscular systems become weak, aerobic metabolism (endurance fitness) undeveloped and biomechanically incorrect through structural misalignments that have accrued from years of stress and layered injuries.
This can be true of even very fit athletes. One fantastic attribute of human brains and bodies is that we are very adaptable. It is possible to achieve very high levels of fitness and physical achievement despite underlying imbalances and challenges that you may have.
However, if you take a deconditioned body and start challenging it with long runs and strenuous workouts, then it stands to reason that you may run an increased risk of an overuse injury, like ITBS.
Running technique is a higher level of conversation that sits above those two schools of thought. While we may be born to run, many people do not use this birthright. Running is a skill, just like any other sport, and if you take a low skilled runner with structural problems and start to step up the millage it again stands to reason that you may start to see problems, and this is likely why running injuries are so common.
At this point, there is not enough high-quality research to say one way or another, but all you need to do is head to a local park on a Saturday morning and spend a quiet few minutes watching the joggers go by. You will see many different styles and techniques out there. You may even notice that the less athletic looking bodes tend to have the more unusual running styles. Could this be down to a simple lack of practice? I’ll let you decide.
My Story With ITBS
I have struggled with this condition a few times throughout my years as an amateur triathlete. The first time was in 2012, and it struck on a long final training run before the Barcelona marathon. Needless to say, I couldn’t participate in the race and was devastated because I had worked so hard to get in shape and I was feeling physically very fit.
Recovery took many weeks and just as I felt like I was fixed the condition would surprisingly reappear after runs of 14km or more. This unfortunate reality prompted me to test out a few different running techniques until I eventually found my groove with a combination of the Pose running method and minimalist running shoes.
The transition from a conventional heal strike to a forefoot running style took time and involved a few minor calf strains along the way, but eventually, I had the technique dialled in and have since completed a marathon, many triathlons, including the Ironman without any ITB problems.
I am a huge fan of the minimalist footwear movement. I think it makes a great deal of sense to be using out feet naturally, allowing them space to move, and striking through the forefoot where our foot arches and Achilles tendon can absorb the forces, rather than heavily impacting through the heal bones, as occurs with conventional running styles.
This does not mean that minimalist or barefoot running styles are for everyone. They require a real commitment to master, as well as proper coaching. There is also no good science at present to support the use of minimalist footwear as a way to reduce injuries. Indeed the science suggests the opposite (due to the awkward transitional period). The adoption of forefoot running is a personal choice and one that makes a lot of sense from an evolutionary standpoint.
There is a lot to consider when it comes to running technique and choice of shoes (you can learn all about how to choose healthy shoes here). This is something that you will need to test out in the real world and find what works for you. As a minimum, I would recommend finding a running coach and seeing if there are any glaringly obvious mistakes that you are making with your technique. Many people run with their pelvis and neck flexed too far forwards, for example. Correcting these issues alone can make a huge difference in the long run by reducing the biomechanical stress load on your body.
Another option worth testing out is spending more time barefoot. You can read more about barefoot therapy here, but just spending time without shoes on, or purchasing a pair of minimal trainers to walk around in and go to the gym in, may well be one of the smartest moves that you make.
Your foot is loaded with important muscles that can become deconditioned and dysfunctional after years of wearing cramped and cushioned modern shoes. This one simple strategy will help to train your feet while you simply go about your day.
I do not recommend running in minimal shoes unless you have had training, coaching as well as a sensible plan for integrating slowly into this new method. There is a transitioning period to work through, where you have to condition your foot and leg muscles to be strong enough and flexible enough to work in this new demanding way.
The Best Treatments For Runner Knee
1. Proper Rest
ITBS is an overuse injury, so the most appropriate and beneficial treatment strategy is rest. It needs to be real rest, however, merely slowing down is not enough. With that being said, it is very hard to stop using your knees, and this is why ITBS is often tricky to treat!
Rest should be your first plan of attack. While ITBS is a relatively minor injury, it is still an injury, and it cannot heal if you keep irritating it. Often runners are so dedicated to their sport that they find resting particularly challenging, but if you don’t allow your knee to rest for the appropriate amount of time, the risk of re-injury is high.
How much should you rest? There is a range that you will fall into. Many cases of ITBS subside after just a couple of weeks of proper resting. It may take twice as long as that, even up to 6 months for the worst cases.
When I reinjured my ITB in 2016 doing a swim-run competition, which involved running a marathon through the mountains, with lots of long downhill sections, it took 4 months of resting to go away. It was difficult to do but at the same time, it was required.
If you are one of the problematic cases that demand extended rest, you should only follow that approach if you see noticeable gains. The pain should be absent while you rest, and periodically you can test it out with a controlled run or by walking down several flights of stairs. If after several months you are finding that the pain is just not subsiding then it is likely that rest by itself is not enough in your case. The decision on how much you rest is personal to you. Some people are ok with prolonged time off, whereas more serious athletes may find this unacceptable and try anything else to get back to running pain-free.
How to maintain your fitness while you rest. Proper resting does not mean that you need to be completely inactive. It means that you must not stress your knees. This can be a difficult concept to accept for many athletes and can even elicit much fear around the loss of fitness and competitive edge. While its true that you will lose some fitness as you rest, the truth is that your fitness and competitive edge were already lost the moment that your knee started hurting. The rest that follows is just a part of the recovery process that allows you to come back stronger in the future, for now, it’s about minimising your losses and healing as quickly as possible. If you fail to heal, then your athletic edge will most certainly be lost, and you may be surprised at how a period of rest allows you to come back stronger and soon recuperate your losses.
Two transition sports that are very effective at helping you to remain fit while reducing knee stress are cycling and swimming. If you are already doing these sports and finding that they bother you may have to get creative and find something different. Perhaps upper body body-weight training in the gym, or a focus on neuromuscular rehabilitation style training with a functional neurologist or personal trainer.
Cycling. The science shows that “the foot pedal forces during cycling are only 18% of those incurred during running while the ITB is in the impingement zone”. This impingement zone is thought to be maximal at 30 degrees of knee flexion, which is probably why so many ITBS problems occur when running or hiking downhill. 16
The trick here is to test it out. If you are already a triathlete, then it is a simple change of focus to spend more time on the bike. You may also want to make sure that your bike has been correctly fitted to your body since small changes in the seat, handlebar and cleat angle can translate to significantly different stresses on your knees and back.
If you have a very significant ITBS then cycling even with the 82% less stress on your ITB may be unwise. You will need to test it out to find out.
Swimming is a very good option because gravity and body weight impact is immediately ruled out and your knee is kept in a relatively neutral position, usually less than the 30 degrees of optimal ITB irritation. Swimming, and also cycling if you don’t train too hard, are also naturally aerobic sports, so you can build true aerobic fitness over time, encouraging your body to burn fat for fuel and limiting the stress response associated with endurance training, turning you into a healthier athlete.
The use of a “pull buoy” (a small figure of eight float) between your thighs will take your knees entirely out of the equation and also make it easier to swim and control your breathing. This is a great option for those with less brilliant swimming skills or very irritable ITBs.
Elliptical machines may well be a good option for you too. They remove the impact multiplier effect of running, and if you engage your core and pelvis correctly as you used them should allow you to get a great workout without stressing your knees. Once again you will need to test this out. I have seen cases of ITBS where the elliptical trainer did aggravate the problem as well as cases where it didn’t.
Nordic walking is the modern discipline of walking with poles to help stabilise and take stress off of your body. It is a great strategy to employ if you have already been through a period of resting and are looking to test your knee out and see how it is doing. If you are a hiker and are susceptible to recurrent ITBS, then these walking poles may make all the difference, since they are particularly helpful when walking downhill.
Avoid the temptation to try running slowly! Running slowly is not the same thing as resting. In fact, it can be counterproductive. Some experts have suggested that running slowly causes your knee to spend more time in the “danger zone” around 30 degrees of flexion, and that could make the problem worse.17 No actual studies have been done to confirm this, but it does make sense, and may well explain the classic onset of ITBS symptoms, which typically start as a sharp pain and progresses reasonably quickly, but not immediately to more severe pain. However, what happens typically after the pain begins? Runners slow down, and they may have already been slowing down due to fatigue and hence spending more time in the danger zone causing problems.
2. Altering Your Running Technique
Since more time spent running in the danger zone (30 degrees of knee flexion) or by landing heavily there are a couple of interesting options to consider, even though they seem opposed to each other.
Running faster with a longer stride length should reduce your time in the danger zone and therefore take some pressure off of the ITB. This generally means that you expend more energy and cannot keep it up for as long. So pacing yourself with say 3-5 minutes of fast running with long strides, followed by walking recovery time, repeated 5-10 times could work for some people to stay fit and rehabilitate their fitness and reintegrate back into running.
The trouble with running quickly is that there can be a heavier foot strike and a greater tendency to go into anaerobic metabolism. This is less desirable for endurance athletes who may be better off running at a slower pace with a shorter stride length and faster cadence. In theory, this may lead to more time spent in the danger zone, but it does allow the runner to land with a softer stride deliberately, and to be more precise with their technique.
Pose running technique, for example, can be performed with low impact foot strike and minimal foot contact time with the floor. These factors together with the ability to maintain a moderate pace over long periods of time in the aerobic training zone may make this the best option for endurance runners. Again, the jury is out, and it comes down to personal preference as well as trial and error on your part.
3. Chiropractic Help For Iliotibial Band Syndrome
As discussed above there is no doubt that posture and structural alignment can have a significant impact on the forces experienced by the knees during running. A simple analogy would be how your car tyres wear out faster and unevenly when the tracking is off.
It is not all just about aligning the bones correctly, it is also about being able to recruit the right muscles at the right time properly. When a joint is misaligned and not moving fully there can be a reduction or loss of afferent proprioceptive nerve input into the brain, which directly changes the motor output and muscle firing patterns. The way that this works is not much different from how you feel when you have a pebble in your show. The pressure of an unusual force through the neural tissues of your foot causes you to adapt your posture to remove that pressure.
There are both ascending and descending problems with the body structure that can lead to injury. Ascending problems are misalignment or injuries or issues with the feel knees, ankles, pelvis or spine, changing the sensory input and motor output response of the brain.
Descending problems are alignment and muscular problems in the jaw and teeth. Malocclusion, or abnormal alignment of the bite (how the upper and lower teeth meet), caused by a dental implant or tooth extraction, for example, can change the alignment of the spine by altering the sensory messages from the teeth and temporomandibular joints into the brain. Again, the change of sensory input creates a change in motor output which can create a torquing effect through the spine.18
There is a growing interest in the link between malocclusion and body structure problems, like scoliosis. In 2005, an experiment was performed on rats where their bite was deliberately change using an occlusal bite pad, and after 1 week they were x-rayed, and all rats had developed scoliosis. Interestingly 1 week after removing this occlusal bite pad and restoring normal dental occlusion the scoliosis was reversed in 83% of rats. More research is required, but there is a strong link between these descending neurological insults and body structure problems.19
A good neurologically focused chiropractor can assess your body alignment and function and determine if you have an ascending or descending structural fault that could be causing the imbalance in your body and contributing your ITBS.
4. Trigger Point Therapy
Trigger points are small bunched up regions within muscle fibres that have a central nidus which can refer pain to far-flung parts of the body. Trigger points are very common, most people have many of them throughout their muscles, yet most of the time they lie dormant and do not refer pain unless you push on them.
Trigger points can become active and start referring pain continuously. Trigger points are notoriously sensitive things, becoming upset by many, even any, changes to normal conditions. Too hot, too cold, too much work, overstretched, too much pressure, you name it, they can become active.
Trigger point referral is a different type of pain to ITBS, but they can be contributing to the clinical picture. The most common trigger points which would be worthwhile assessing and correcting are the vastus lateralis, the gluteus medius and the peroneus longus muscles (check out this excellent website to learn the location and pain referral patterns of these muscles, and all of the others!). To treat these trigger points you can feel around the muscle until you find the painful nodule and then apply pressure with the tip of your thumb or with a tennis or hockey ball. If you are in the right spot, the trigger point will refer pain and it will be pretty unpleasant. Continue to hold the same pressure until the pain starts to subside (it may not go away completely) and then follow up with stretching the muscle.
A good chiropractor, osteopath or physiotherapist should also know how to incorporate trigger point therapy into your program of care.
4. Soft Knee Straps
These are a sports band that you wrap around the thigh just above the knee joint. They often have a built-up firmer section that goes against the ITB. The
whole band is tightened slightly to provide pressure to the ITB.
They do seem to show promising results for many people suffering from ITBS and are worth trying out, but not for the reason that you may think.
It is tempting to think that these bands work by providing a new point of tension or friction for the ITB thus taking the pressure off of the sore point, but that is highly unlikely to be the mechanism providing relief.
If you remember earlier in this blog post, I described the deep layer of fat cells that sit around and underneath the ITB tendon. These fat cells are richly innervated and provide the brain with proprioceptive feedback about the position and health of the knee joint. Pain provides a different sort of feedback, something known as nociception which can cause a very different motor output from the brain as well as the sensation of pain.
By placing the band just about this point it is likely to change the way the nerves around this area talk to the brain, and this altered proprioceptive feedback may reduce the nociception, therefore reducing pain, as well as help to restore normal motor feedback to stabilise the joint better. Indeed there are studies to show how these taping and strapping techniques change the way that the brain works, by altering this proprioception, which is also known as our “sixth sense”.
There are many of these ITB Compression Wraps/Bands available on the market. Heres an example of the sort of thing to look for.
You can wear this strap while cycling, running, walking, c=sleepin or anytime you want to protect your knee from the pain of ITBS. Some athletes I have treated have worn it throughout the day, every-day until pain-free. You could even make do with kinesiotape or cohesive bandage tape whilst you wait for your band to be delivered.
When using this band you may experience some chafing and blisters, especially behind the knee. To avoid this happening use some Vaseline or Chamois anti-chafing cream.
5. Low-Level Laser Therapy (LLLT)
This is one of the fringe treatments that is increasingly being shown to help with many chronic pain conditions and injuries.
Therapeutic lasers work by supplying energy to the body in the form of photons of light. The tissues and cells then absorb this energy, where it is used to accelerate the rate of tissue healing.
Therapeutic Benefits of Laser Therapy are known to include:
- Anti-inflammatory Action: LLLT reduces swelling, leading to decreased pain, less stiffness, and a faster return to normal joint and muscle function.
- Rapid Cell Growth: LLLT accelerates cellular reproduction and growth.
- Faster Wound Healing: LLLT stimulates fibroblast development and accelerates collagen synthesis in damaged tissue.
- Reduced Fibrous Tissue Formation: LLLT reduces the formation of scar tissue, leading to more complete healing, with less chance of weakness and re-injury later.
- Increased Vascular Activity: LLLT increases blood flow to the injured area.
- Stimulated Nerve Function: LLLT speeds nerve cell processes which may decrease pain and numbness associated with nerve-related conditions.
That’s an impressive list of positive effects. A full discussion of LLLT is beyond the scope of this blog post, you can read more about it here, including a podcast episode I recorded with Red Light Rising, here.
I could not find any studies directly linking LLLT as an effective treatment strategy for ITBS, but numerous studies have reviewed its effectiveness as a treatment for other sports injuries. To give just a few examples, LLLT has been shown to be useful for jumper’s knee, tennis elbow and Achilles tendonitis, tennis elbow, neck pain, muscle fatigue, post work out recovery, shoulder impingement syndrome, chronic neck pain shoulder pain and heal pain from plantar fasciitis.20,21,22,23,24,25,26
Icing and cold treatments have been used to treat injuries since the ancient Greek times. There has been shown to be both an analgesic (pain reducing) as well as a slowing effect of inflammation and swelling.
The way that most people ice an injury is to place a cold pack or bag of frozen peas over the injured area for 10-15 minutes. This will likely have a minimal effect on an injury like ITBS.
Instead, carefully try the following approach, as take care to not give yourself an ice burn.
If you put raw ice on your skin for more than 2 minutes at a time you may give yourself frostbite. Please take care if you try this approach
- Get a cardboard coffee cup, fill to the tip with water and place in the freezer until its frozen
- Feel back or cut off the top 1 cm of the cup – this makes a convenient ice holder.
- Rub the ice in quick circles around the area where you experience the greatest degree of pain when the knee is slightly bent, until the area feels numb (but for no longer than two minutes at a time).
- Stop if the skin starts to feel burning and avoid bony parts like the front of the knee.
- Attempt 3-4 sessions per day
Icing can be done while you watch TV or speak on the phone or any other relatively sedentary task. This type of multitasking can make it easier to keep up with the habit until you are healed. Once you are pain-free you can stop icing.
Treatments To Avoid
The two main treatments to avoid also happen to be the most popular: Foam rolling or deep tissue massage and stretching – with the intention of lengthening the IT band.
I believe it only takes a little bit of common sense to see why these treatments are not a good use of your time.
Lets first consider what the ITB is, it is very tough tissue made of fascia and tendon, which is stronger than steel cable. Tendons almost never rupture in sports injuries and accidents. Muscle will tear or the tendon will pull off of the bone (called an avulsion fracture) long before the forces get large enough to rupture a tendon.
The ITB is also anchored down to the femur throughout its length. So attempting to stretch this by contorting yourself into a gut-busting straight leg pelvis tilt and twist scenario spare a moment to think about the reality of what’s happening.
If your ITB was removed from your body and fixed to the ceiling, you could hang off of it with your entire body weight and fail to stretch or elongate it. Just like you wouldn’t expect to be able to stretch a thick leather belt by pulling on it. When you think about the amount of force you can create with your own body during a stretch, this approach becomes even sillier.
Equally, when it comes to deep tissue massage, Rolfing or Graston techniques, you are no more likely to be able to elongate an ITB with direct pressure than you are a leather belt. Imagine trying to deep tissue massage our belt to increase in length. It’s just not going to happen.
A lot of precious healing time and money can be lost by perusing these sort of approaches when there is no plausible way in which they could work.
A note on stretching. It is possible that you may be able to slightly reduce the mechanical tension on the ITB by stretching the tensor fascia lata, as well as other hip, muscles (you can easily find these sorts of stretches on youtube), However, it is likely to be of only limited benefit. By loosening the TFL muscle you may take some stress out of the side of your knee, but it will likely be minimal and short-lived and not get to the real crux of the problem.
The research on stretching to treat or prevent injuries of any description is scanty, to say the least. There is more research to show that stretching does not reduce your risk of injury or do anything to treat ITBS.27
This doesn’t mean that you shouldn’t do any stretching, it means just don’t rely on them completely to heal your condition.
Runners’ knee is a complicated and frustrating condition, especially when it fails to self-resolve within the first 2-4 weeks of rest. Remember that out of all of the treatment strategies available, a careful and proper program of rest and self-care may well be your best chance of making a full recovery and getting back to racing. Trying to stretch, massage or ibuprofen it away is probably the least effective strategies which may lead to right back to where you started, several weeks from now when you attempt to run again. Getting a full functional assessment from an excellent chiropractor may also be a good initial strategy because it’s important to find out the cause of any joint or muscular balance issues to avoid mechanically stressing the ITB when you start running again.
Now id like to hear from you. Have you suffered from ITBS? What did you do to recover? What worked and didn’t work in your treatment of this common problem? Place your comments in the box below.
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