As I sit down to write this blog on a magnificent sunny Sunday morning devoid of wind, most athletes who entered the Melbourne marathon will have completed the event (Apologies to those people who are still running into the stiff breeze that appeared mid-morning!). Of those that lined up on the start line, some will have done so carrying an injury and some will have developed an injury as a result of competing.
Sadly, some of the people that entered the event will not have been able to compete due to an injury. The few weeks leading into the Melbourne Marathon is a busy time for most of the physios at Lake Health Group, as runners succumb to the injuries that result from pounding the pavement in the lead-up to what is probably not a natural event for many human bodies: running 42 plus kilometres in a single stretch.
“I felt like someone had stabbed me in the side of the knee“
“The pain hit me at 10km and got progressively worse until I had to stop and walk with a stiff leg”
“When it`s bad I can`t bend my knee“
These are but a few of the descriptors of pain and symptoms that patients have presented with in the last month or so while training for this gruelling event. A lot of these patients have a rough idea of what may be wrong with their knee thanks to the easily accessible ‘Dr Google’, as well as the rest of the running fraternity and their training partners, who may have experienced something similar. Well what is the injury you are talking about? I hear you ask.
The answer is that the most common cause of lateral knee pain is iliotibial band friction syndrome (ITBFS), which is an overuse injury. There are however quite a few other injuries to the lateral knee that need consideration and should not be overlooked.
ITBFS is a repetitive strain type injury that occurs prolifically in runners, cyclists and endurance athletes. As running is the basis of most sports, it is an extremely common problem. Before I discuss the signs and symptoms, a brief anatomical overview is useful in helping people to understand how the injury occurs.
What is the ITB and what does it do?
The iliotibial band is a thickened band of connective tissue on the whole outside of the top part of the thigh .The ITB gains insertions from 2 muscles near the top part of the hip, those being the little known tensor fascia lata (the little egg shaped muscle at the front/side) and the better known gluteus maximus muscle. It inserts all the way along the femur (top thigh bone) and finishes up down near the knee. Here it acts like the lateral ligament attaching to the outside of the kneecap and onto the tibia (main shank bone). That is why often “runner’s knee” or mal-tracking of the kneecap can be caused by a tight ITB. The ITB plays a major role in stability of the hip, it also assists in keeping the pelvis level when standing on one leg and guess what? Essentially good form in running relies on this.
So what are the signs and symptoms of ITB syndrome and why does it occur? As the name suggests it is a friction syndrome whereby the ITB rubs on a prominent section of the femur bone called the lateral femoral condyle. There are a few bits of tissue that are supposed to cushion the band as it moves back and forth over this lump of bone but sometimes they become inflamed. This tissue and bursa (small sack of fluid) has a very good nerve and blood supply and is probably the cause of pain in the condition. The reason that most people end up walking with a stiff leg when symptoms are bad is that the ITB contacts the lateral condyle at about 30 degrees. When the knee extends past this, the ITB clears the condyle and doesn`t create the friction. The other load that the ITB doesn`t like is compression and if a runner has poor hip control and drops his hips while in the stance phase (and even worse has excessive internal tibial rotation plus crosses the midline), compression forces on the condyle and band increase and can lead to symptoms. It must be pointed out at this time that there are a few other things that can commonly cause pain on the side of the knee besides the ITB. Patellofemoral (knee cap) syndrome, lateral meniscus tears and lateral compartment osteoarthritis may also give similar pains. The lateral hamstring and the joint between the tibia and fibula can also be responsible for pain in the area. Lastly the lower back has been known to refer to this region, so things aren’t quite as simple as Dr Google may have us believe.
Now that we have outlined the symptoms, how does one treat this condition?
When I first graduated from physio school, the standard treatment was a bit of massage, stretching of the ITB and 6 weeks off running. I can hear all you cynics out there saying “yeah, so what’s changed?” but I believe our understanding of biomechanics and the nature of tendon like injuries plus the importance of core and hip stability makes physios much better at treating this condition than a few years ago. A Physio should not just address the local symptoms, but also the hip and foot, local treatment can include ice and electrotherapy to the lateral femoral condyle and in some cases that fail to settle a cortisone injection may be indicated. This can be done either in rooms or under ultrasound guidance. It must be noted that it is important that the patient understands that the cortisone is not the “cure all” and that they must address all the other issues that may have contributed to the injury in the first place. Otherwise an incomplete recovery and recurrence can occur.
Soft tissue massage to the ITB , dry needling and self-massage with a foam roller are all good for reducing muscle tension and tone in the ITB. Interestingly stretching of the ITB can cause compression of the ITB down near the knee and is often not that effective. It is far more effective to stretch the gluteal and other muscles around the thigh. Massage or dry needling of trigger points in the gluts and tensor fascia lata can help. Strengthening the hip rotators as well as the abductors (hip stabilisers) is a critical part of the management of the condition as resting will do nothing to correct underlying weakness and early onset of fatigue in these muscle groups. A slow and progressive return to running may need to be considered to prevent recurrence of ITBFS.
Having had a lot of trouble personally with an ITB injury many years ago whereby conservative management failed, I can vouch for the fact that sometimes surgery to release the ITB can be very effective. Obviously this is a last resort and must only be performed if the physio and surgeon are convinced all other avenues to rehabilitate the knee have been tried and failed.
So in summary, pain in the side of the knee with running can be quite debilitating and can often be caused by an Iliotibial band friction syndrome (ITBFS), but other causes of pain such as a lateral meniscal tear or arthritis need to be considered. Hip and foot/ankle stability are important considerations in the treatment of ITBFS and strengthening of these areas plus the core should be combined with other manual physio techniques to ensure a good result. If running a half or full marathon, or even jogging a lap of the lake, is important to you, chances are you or someone you know will encounter this condition. The good news is that at least now you will be aware of the possibilities and know that effective treatment is available.