Are You A Runner Suffering From ITB Knee Pain? Physio CAN HELP!
Are you a runner, hiker or walker who has been trying to increase your training but have suffered pain on the outside of the knee? This frustrating pain may be due to the ITB!
What is the ITB?
The ITB stands for Iliotibial Band. This is a strong fibrous tissue that runs from the outside of the hip, along the outside of the thigh and into the outside (lateral) knee. The ITB acts almost like a tendon that helps transfer force to and from the hip and outside knee.
A side on view of the ITB
How does ITB knee pain occur?
All running injuries are caused by an imbalance in running volume and tissue capacity - doing too much, too quickly. ITB pain is no different.
If you track your running log there will be some sort of spike recently - an increase in km, a big race, an increase in frequency or different terrain - hills, trails etc.
We often see accomplished runners who have years of running under their belt get these flare ups. Or runners who have taken a large time off (kids, work etc) will return to running and feel fine aerobically, but their legs have not adapted to the load.
This could be at times after holidays, they may have deloaded or taken a few weeks off, then returned back to their normal training which spikes their loads.
About ITB Pain:
ITB was previously called ITB Friction Syndrome. We now know the anatomy of the tissue does not allow it to ‘friction’ outside the knee.
The ITB is firmly connected to the lateral femoral condyle and supracondylar ridge stopping the ITB from moving side to side over the lateral epicondyle (the bony part sticking on the outside of the knee) - in simple terms there is no friction there.
Instead, in an overloaded runner, the highly innervated (lots of sensory nerves) adipose/fat tissue that provides padding between the ITB and lateral femoral condyle is compressed when the knee bends past 30 degrees and peak tension is reached in the ITB. This compression of fat tissue is the driver of pain.
Pain will be focal over the lateral femoral condyle as the knee bends and straightens over a 25-35 degree painful arc. Pain will come on as the tensor fascia latae muscle is loaded eccentrically - as the hip extends (straightens) while the knee flexes.
This is most common during downhill running, descending stairs or running on a narrow pathway (i.e. parts of a trail run).
Running on narrow trails encourages the hip to adduct (foot strike overlapping midline) which increases loading through the ITB
Downhill running can cause increased loads through the ITB
Why is ITB injury so persistent and hard to overcome?
ITB pain can linger for months. Runners will often go through a deloading cycle. When the ITB/outside of the knee becomes sore, runners will rest. The pain will decrease initially, but when they try to increase running back to near normal levels, the pain will come back.
This is because during full rest the legs decondition and lose their running capacity. A runner’s previous 10km capacity may drop to 5km, so when they try to run 6km suddenly the ITB flares up. This cycle repeats until the running capacity is negligible.
Rehab involves keeping runners maintaining their running volume as much as they can safely tolerate. This may be with running on alternate days, decreasing volume, interval training, eliminating downhill running and narrow trail running.
What can I do to help ITB pain?
ITB STRETCHING. Stretching the ITB can cause increased compression at its insertion at the outside knee, and may cause pain or make symptoms worse. The ITB has minimal ability to lengthen so stretching is not going to help!
FOAM ROLLING ITB. The ITB will often feel tight and tender to touch. People often roll out the ITB like a tight muscle, sometimes with hard objects like a PVC pipe or rolling pin.
This often irritates the ITB more as it increases compression of the tissue. Rolling out the glute max, glute med/min, TFL and lateral quads is much more effective and less provocative.
DOWNHILL Running and walking. When going downhill the body is constantly trying to decelerate. This causes a lot of extra effort of the knee, and this force will be transferred through the ITB into the hip. Often downhill running is painful for ITB syndrome, and may be the cause.
FULLY RESTING (unless pain is excruciating). Prolonged full rest will cause deconditioning in your running capacity
Improve hip strength
There will be a loss of hip (abductor) strength with ITB pain. Majority of the time the weakness is caused by the pain in the ITB, rarely the other way around.
Maintain Safe Running Levels
It is important not to stop running fully - as this can lead to running deconditioning.
Generally we are happy to keep running at a level where pain is <2-3/10, is not flaring up during, after or the next day from a run.
Running every 2-3 days is useful to allow the muscles to relax post run
Interval training can be useful if ITB pain is very moderate
Progressive increase weekly loads as pain settles and rehab exercises progress
Maintain fitness on a treadmill through uphill running/walking. Treadmills are great on an incline because you can run uphill (a very safe activity for the ITB) whilst avoiding running downhill (aggravator)
Uphill treadmill running/walking reduces knee varus whilst increasing knee flexion at footstrike. This generally avoids the ITB compression zone of 30 degrees knee flexion.
Potentially change running mechanics (for the short term)
Increasing the cadence and running with a slightly wider stance may be beneficial in the short term to reduce ITB compression.
Improve kinetic chain deficits:
Physiotherapist Lindon performing hip abduction strengthening rehab
If you are a runner who has experienced pain on the outside of your knee, and you think you might have ITB pain, book in to see one of our expert physiotherapists at Melbourne Sports Physiotherapy. We have clinics in Essendon, North Melbourne and Blackburn who love rehabbing running injuries.
How can we help you?
At Melbourne Sports Physiotherapy our goal is to get you moving pain free as soon as possible.
But, we also want you to actually move better and live a healthier, more active and fulfilling life!
If your sports, fitness training or work has been wearing your body down, book in with one of our expert massage therapists so we can help you reduce your pain or stiffness.
If you are showing some signs of this condition or simply want help prevent this from happening in the future then book in with one of our highly experienced Remedial Massage Therapists today!