Knee pain at the iliotibial band: What can you do about it?

Description: Iliotibial band syndrome, or ITBS, is one of the more common injuries affecting runners. And why is that? Probably because the same faulty motor patterns and muscle weaknesses tend to run rampant amongst many runners. ITBS tends to come on gradually, causing a lateral knee pain, though some runners are able to bring on the pain in a single run of greater distance or intensity than their typical. It is often another story of too much, too fast.

Anatomy: The muscles that attach to the ITB are from the hip and thigh region: gluteus maximus, vastus lateralis and tensor fascia latae. The far end of the ITB splits into several sections, which indicates it has a role in the function of many areas. Most commonly athletes will complain of pain where the ITB interacts closely with the lateral femoral condyle.

Cause: The primary function of the ITB is to stabilize the knee during walking and running gait. When some of the hip muscles are weak, the ITB can be relied upon too heavily for knee stability, thus stressing its lower attachment excessively.

Signs and symptoms: The far end of the ITB can flare up like a tendonitis does when initially becoming inflamed. There can be inflammation at the bursa that sits beneath the ITB as well. As a result, you might notice swelling and tenderness to touch at the outer knee where the ITB crosses. There can be a snapping or popping sensation at the lateral knee. The pain tends to take on a sharp and stabbing quality when there is demand placed on the leg but the general area may be achy after use. 

A common finding in many instances of ITB syndrome is hip muscle weakness, particularly of the gluteus medius and gluteus maximus muscles. There may be a decreased ability of the nervous system to activate and control those hip muscles while running, even if they are strong in testing.

This demonstrates poor engagement of the right hip abductors

This demonstrates poor engagement of the right hip abductors

An indicator of poor gluteus medius activation is an excessive dropping of the opposite side of the pelvis when the affected leg is in stance. One way you can check this is to stand in front of a mirror, hands on your hips, and then shifting yourself onto one leg. For instance, if you move onto the left leg and the right side of the pelvis clearly drops then you have a positive Trendelenburg's sign. Check both sides as it is common to have an asymmetry. In the video below I demonstrate both the active position and inactive position. The same excess of pelvic motion can occur in walking and running. 

Solutions: As with many of these injuries, there is no magic pill and no quick fix. Consistent but brief supplemental work is the reliable solution.

1. Some physicians may promote injecting the bursa region that lies between the femur and the end of the ITB. Corticosteroid injection should be a last resort as recurrence is very likely if the mechanical control of the hip and knee are not addressed. I have had patients where injection was used as a first line treatment. Guess what? The pain came back. At least this is a lower risk area to inject with corticosteroid as the risk of ITB rupture is minimal compared to an area like the Achilles tendon or posterior tibialis tendon. The side of the quadriceps is probably more likely to rupture. Remember, injections do not address the mechanical reasons the injury occurred in the first place.

2. The very first and simplest issue to address is the presence of any weak muscles at the lateral side and back of the hip. These muscles need to be activated easily and consistently by the nervous system. So many people have weak muscles around their hips, trunk, and pelvis so don't assume you are an exception. It is a daily occurrence for me to see these issues in the clinic. 

Athletes need a baseline level of strength and the ability to effectively recruit these muscles while running to prevent the pelvis and hips from destabilizing. Poor strength or activation may allow the thigh to collapse inward or rotate inward along with an unleveling of the pelvis. It’s also important to consider the endurance of these muscles because the strength will undoubtedly be decreased a few miles into a run or fatiguing workout.

As a side note, I have seen so many patients that were correctly told to perform exercises like a side lying straight leg raise only to discover they are doing it in a manner that works the wrong muscles because no one checked their technique. Their form was incorrect and doing these exercises incorrectly can actually contribute to the problem. Not only are the wrong muscles used (eg. tensor fascia latae), they are creating a dominance in areas that further inhibit the function of the correct muscles (eg. gluteus maximus).

Here's the routine that I do on a weekly basis. 

3. As the awareness, endurance, and strength are all starting to increase, it is necessary to challenge the nervous system’s ability to stabilize the hips and pelvis. Single leg balancing activities are a great program component to do this. The individual must recognize where the pelvis achieves a stable position in order for this to be effective. This can progress to single leg hopping and jumping activities while keeping the pelvis stable.

4. There has been some controversy over whether athletes should foam roll their ITB, which I discussed previously here. Don’t bother trying to stretch your ITB unless you like to waste time and potentially worsen the problem. Most ITB stretches simply stretch the hip muscles that are already weak, which is absolutely counterproductive. And the ITB’s connective tissue is extraordinarily strong so you aren’t going to stretch it.

image courtesy 220triathlon.com

image courtesy 220triathlon.com

5. Running technique changes can be effective to normalize demands on the hip muscles and move in a less painful range of motion. The knee needs to maintain a high level of bend during swing. If you have a tendency to overstride far forward of the body’s center of mass then you will place greater demand on the gluteus medius muscle as soon as the foot makes contact, setting yourself up for failure. You may only need to increase your cadence 4-6 steps per minute and think of nothing else. There’s more information on cadence changes in my shin splint article here. The relationship of the ITB to the femur bone beneath it also changes as the knee is bent and straightened so changing the technique can change that relationship. In some runners there can be a benefit to running quickly for 20-30 seconds and then walking to vary the mechanical position of the ITB to the femur.

Poor right hip abductor engagement

Poor right hip abductor engagement

6. If you have been unable to exercise secondary to ITB pain, make sure you take full recovery days between the days that you do start to exercise. These off days are great to emphasize the strengthening, balance, maintenance, and so on. For running that first time back, short and consistent is the name of the game. Better to run one mile each on three or four days than three to four miles at once. Depending on the number of days you have taken off, a mile isn’t an unreasonable distance to start at and that may also require a walk/run program. 

Please let me know if you have any questions at derek@mountainridgept.com. 

Highlands Sky 40 Mile Trail Run: Best Race for Anyone with Achy Feet

Super tame section of Canaan singletrack

Super tame section of Canaan singletrack

The neverending boulder fields, rock-strewn trails, endless bogs, and cold stream crossings will provide your feet with the nice, soothing care that they deserve. I wish I lived closer to the course so I could run it after work on days when my feet are a little achy.

Seriously though, this is a brutal course, at least through the beginning miles. For those of you unfamiliar with the event, the point-to-point course traverses the Canaan Valley and Dolly Sods areas in the Monongahela National Forest.

Despite doing my homework by asking prior competitors about the terrain, stalking Strava segments, and searching YouTube, I could have known so much more about the course. There is no substitute for experience and having never done the event it’s hard to know what to expect. But that’s also part of what makes the challenge more exciting.

Pre-race

The pre-race dinner at Canaan Valley Resort was great. There was a nice variety of carb-heavy food and local craft beer from Mountain State Brewing. Several high quality door prizes were given away. I won coffee from Sweet Bloom Coffee Roasters and as of this morning I've decided it's the best coffee I've ever made at home. 

Most racers stay at the resort but I ended up staying at the Timberline Ski Resort, which I would see around mile 35 in the following day’s run. I awoke at 4:00 AM and began the typical race morning preparation with the special hotel rendition of my classic breakfast sandwich: 1 everything bagel, 4 slices of bacon, and 1 egg. After a banana for dessert I was on my way out the door.

Bacon makes you faster not fatter

Bacon makes you faster not fatter

Start

My wife and I drove down to the starting area in Laneville, WV, arriving around 5:30 AM. It was a little chilly for standing (because I’m a wuss), but perfect for running. The forecast was calling for very nice sunny and slightly warmer weather. Wish I could duplicate that for every race. I’d heard rumors that the top competitors started out hard and fast to avoid a bottleneck at the trailhead. That was definitely true, as I was running around 7 minutes per mile on the paved road until we hit the trail around mile two and there were runners in front of me going even faster.

Almost go time

Almost go time

We then began the long ascent from Laneville, WV up the mountain toward the Dolly Sods area. We made our way through multiple mountain stream crossings and large, unforgiving patches of stinging nettles. A pack of five guys formed in front of me going up that 6-mile climb, and the current leader was well off of the front. The pack of five eventually became a pack of three, as two dropped off behind me. I had to make the decision early to let them run away from me as I was pushing my heart rate well into heart rate zone 5 and I don’t even do that in the early miles of a road marathon!

Frolic in the ferns

After getting to aid station #2 one runner caught me and I dug deep to stay near to him as we descended into another large ravine. It’s not always the climbs that are hard on your legs. If it hadn’t hurt me so much I would have liked that descent more because it was laden with ferns.

Entering Dolly Sods

I did eventually catch that group and was able to stay in front of them for the entirety of the race. But in my efforts, I mistakenly pushed myself a bit too much, too early. The upper portion of the mountain became quite steep in places, enough to require use of the arms and hands to climb. I quickly learned that these were some of the most true and unforgiving mountain trails that I have ever raced. I came into the halfway point in second place, wondering how rough I was really going to feel by mile 30, knowing the early course had taken a toll. As an aside, I’m voting aid station #4 the best on the course for their high level of enthusiasm!

Multitasking food, shoes, and socks with fantastic volunteers

Multitasking food, shoes, and socks with fantastic volunteers

Friend Daniel Hanks shaving his legs at the halfway point

Friend Daniel Hanks shaving his legs at the halfway point

Road Across the Sky

Running the stretch of gravel road known as the Road Across the Sky, I could gradually feel my efforts catching up to me. It was difficult to run under 9 minutes per mile on a section where I should have been able to do 8 minutes easily. As a result, two runners caught me.

By the time mile 30 was approaching, I was definitely depleted more than I expected. Nothing like making a beginner mistake. I began hiking uphill sections where I would normally run.  

Those couple miles up to mile 33 were not fun, as the terrain was exposed to full sun and at over 5 hours into the event I was becoming emotionally and physically drained and that allowed yet another runner to catch me. Very demotivating. He was doing what I usually strive to do: negative split!

I felt like my nutritional intake was lagging behind and that contributed to my suffering. Speaking of nutrition, here’s what I ate and drank during the race:

  • 4 Gu gels
  • 1 peanut butter and jelly sandwich
  • 2.5 bananas, 2.5 liters of water
  • 3 oz. pickle juice, 3 dill pickle spears
  • 6 Oreo cookies
  • handful of plain M & Ms
  • handful of trail mix
  • 2 salted boiled potato slices
  • 12 oz. Coca Cola

Stupid knee

At mile 33 I started to have right lateral knee pain. I briefly forgot about it at aid station #7, but when I took off running again it reminded me of its presence less than 100 yards from the aid station. The intensity grew rapidly and substantially. I couldn’t even walk without pain and I was forced to limp. That was incredibly discouraging. I began to mentally prepare to walk the final 7 miles of the event, hoping to somehow hang on for a top 10 finish.

Butt Slide

But I actually didn’t have to walk that much as I began descending from the ridge. My inner Physical Therapist kicked in and told me to look for the fatigue-related running pattern changes. I noticed that I was disengaging my right quadriceps and allow my right knee to snap backward a little. The muscle just wanted to be lazy. And I know I have a history of landing with my right foot closer to centerline (i.e., crossing inward). I realized that if I just ran with the knee slightly more flexed and with a wider stance, the pain began to consistently subside.

All of my consistent strength training paid off because I had reliable quads on the steep downhill section affectionately known as “Butt Slide.” However, just out of the fear of pain returning I remained timid on the downhills and technical sections through mile 35. At one point the trail became less obvious I was wandering aimlessly for about a minute on that hillside. Trusting my directional instinct fortunately brought me back to the red flags on trail.

Road Race

I had recovered very well from the 2 miles of easier running. The flat gravel and paved road from that point on gave me hope that I could run quickly without tweaking my knee. As I approached the final aid station I could see one of the runners who had passed me on the Road Across the Sky. I downed 2 cups of Coca-Cola at aid station #8 and took off with a new motivation. It became a road race from mile 37 to 40. I managed to move up a place at the start of mile 38.

Finish

I ultimately finished up 4th overall, which makes me happy having never raced there before. That was definitely slower than where I wanted to be but the reasons were very clear to me. That course is a true challenge and quite beautiful. It would be great to run parts of it again while taking more time to stop and appreciate the surroundings. When trying to run hard there is so much time spent staring at the ground, hoping not to fall or twist an ankle. I will be back. 

Happy to be done and excited to have run the final 7 miles

Happy to be done and excited to have run the final 7 miles

Thanks

Special thanks to Dan Lehman, Adam Casseday and the rest of the WV Mountain Trail Runners crew for putting on such an awesome event, really caring about the racers, and giving out some cool prizes. And a big thanks to my wife for driving my tired butt home and crewing for me. And thanks to Pearl Izumi for the sponsorship this season. 

To Foam Roll the IT Band or Not to Foam Roll the IT Band?

There are about 50,000 articles on rolling or not rolling the IT band, or iliotibial band, on the internet right now. So now there’s 50,001 with my addition. There’s every topic from “you’ll never get the ITB to stretch out” to “don’t roll it because the problem is actually at your hip” to “keep rolling the ITB.”

I agree, the ITB is so thick and strong you are wasting your time to try to specifically stretch it or roll it out. According to an older article (1931) from the Journal of Bone and Joint Surgery by C.M. Gratz, MD:

“The specific gravity of fascia lata is about 1.31 and the average ultimate tensile strength is approximately 7,000 pounds per square inch. Soft steel has a specific gravity of 7.83 and an ultimate strength of about 45,000 pounds per square inch. Thus fascia lata is nearly as strong as soft steel, weight for weight.”

Image courtesy MedBridge Education

Image courtesy MedBridge Education

The IT band needs to be a strong material. The IT band functions are to stabilize your knee and produce hip movement by working along with the tensor fascia latae and gluteus maximus muscles (refer to the image below). And yes, lateral knee overuse injuries, including IT band region problems, tend to be related to weakness or abnormal activity at the hip and trunk muscles. Maybe something is wrong down at the ankle and foot too.

You shouldn’t be relying on the rolling, or any soft tissue technique for that matter, to make up for lost strength or bad exercise mechanics. Those body mechanics need addressed and your strength needs to improve. It wouldn’t surprise me that a lateral knee pain sufferer would also have weak gluteus medius and gluteus maximus muscles. Most people could use stronger glutes. And maybe you shouldn't have suddenly done a 2 hour long workout when your longest had been 1 hour. 

What the anti-rolling crowd is forgetting is the fact that the IT band is covering a pretty big portion of quadriceps muscle. Because it’s generally a positive to routinely roll or massage the rest of the quadriceps, why would you suddenly neglect such a big part of it? I wouldn’t, personally.

And what if that lateral knee pain is actually coming from trigger points in the quadriceps? At least the rolling was helping to keep the quadriceps relaxed and generally making the nervous system happier.

If you bought into the “no ITB rolling” philosophy, think it over again. At the very least, use a tennis or lacrosse ball to roll the thigh directly in front of the IT band and directly behind it. Take care of your quadriceps and hamstrings muscles. Use the ball, massage stick, or foam roller on the tensor fascia latae muscle too, up at the front/side of each hip.

Strengthen your hips and keep on rolling.