Runner’s Knee is the common name for “Ilio-Tibial Band Friction Syndrome.” The Ilio-Tibial Band (ITB) is a long band of very strong tissue that runs from the lateral crest of the hip down the side of the thigh, attaching just below the knee joint (you can feel it on the outer side of the knee, just above the joint). Pain is caused when the IT Band rubs across the bony prominence on the outer side of the knee. This causes inflammation and pain; and commonly also local swelling and stiffness.
The ITB has a small muscle component called Tensor Fascia Lata (TFL). TFL sits high in the band near the hip and contracts to pull on the ITB. In doing so it controls the position of the foot as it hits the ground. TFL can also assist to stabilise the trunk and pelvis over the leg as we land in running (but it isn’t very good at doing this on its own). Stability of the trunk is a product of many muscles including the gluteals (gluteus maximus, medius and minimus) and hip rotators. When these muscles don’t work effectively, the trunk and pelvis shift sideways which increases the tension in the ITB. This tension causes friction over the bony part at the side of the knee, resulting in pain and inflammation.
Runners knee was once thought to result from an inflamed bursae under the band but studies in recent years have shown this to be less likely as a cause (researchers don’t think the bursae is actually involved at all). Despite some controversy surrounding the anatomy involved, what is certain is that Runner’s Knee is painful and relates to your biomechanics.
As the name suggests, Runner’s Knee affects runners but is also be common in other sports such as cycling, football and hockey. The symptoms usually come on gradually and can be related to an increase in training volume or hill sessions. Sometimes the symptoms come on more acutely with speed sessions, changes of direction or plyometrics.
Runner’s Knee usually presents as a localised tenderness and swelling over the side of the knee. The knee is stiff and painful at the start of an exercise session before then settling as you get going. The pain returns later on in the session. When more irritated, pain can more constant. Pain is often worse in the mornings and when moving after periods of rest.
When should I seek help?
There are many different knee problems that affect runners and these need varying amounts of attention. It is important that you always seek medical assistance if an injury occurs from trauma (such as with a specific twisting action) or if the knee gives way or swells in the joint.
With Runner’s Knee, it is possible that the pain may settle on its own with a little rest, ice and stretching, but when the pain persists for more than a few runs, or if it is getting worse, you should seek the assistance of a sports physiotherapist or other medical professional. There are many members of the sports medicine team that are able to help, and a good professional will advise you how other members of the sports medicine team may be able to help you individually.
A good Sports Physiotherapist is usually the best person to see first. They will be able to diagnose and treat your injury as well as give you exercises to help you manage the injury and prevent recurrence. Treatment of runner’s knee is usually fairly straight forward, although can take quite some time to settle down.
How do you treat ITB problems?
The best advice for initial self-treatment is to avoid the aggravating activity and to ice the area every few hours when painful. You can also try anti-inflammatory gels or anti-inflammatory medications such as Ibuprofen which may also help (we recommend you seek your pharmacist’s or doctor’s advice).
The physiotherapist will massage and mobilise the area to reduce the stiffness, as well as show you exercises to strengthen and re-train the muscles that stabilise the pelvis and trunk. The main muscles to strengthen are the gluteals - these can be worked with exercises such as calms, standing hip abduction, step ups and bridging.
The ITB is sometimes described as being too “tight”. In reality, the tightness is more due to the overactive muscles around the ITB, rather than the ITB itself. TFL can be stretched a little, but the ITB itself has tensile properties similar to Kevlar, so it is really quite unlikely that traditional “ITB” stretches are of much use. It is a good idea to stretching the muscle groups around the thigh (gluteals, quadriceps and hamstrings); but trying to stretch the ITB itself is not that useful. Rolling on a foam roller for regular self-massage is a better idea, and a Sports Massage can also be helpful.
When the symptoms of Runners Knee don’t improve, or take too long to improve, it is can be necessary to seek further advice and management from a Sports Doctor or Orthopaedic Consultant who specialises in knee injuries. A Specialist may request an MRI to confirm the diagnosis or rule out other problems in the knee. In some cases the Specialist may suggest an injection of corticosteroid. Cortisone is a very strong anti-inflammatory drug that acts locally and can settle the pain quite quickly, but should only be used in special circumstances. Where the pain doesn’t improve despite all other interventions, an Orthopaedic Surgeon may recommend an operation to release the ITB, but this is only ever the case for a very small number of people.
Getting back to running
When not able to run; swimming, cycling and the elliptical trainer are good ways to keep up your fitness. Once the pain settles enough, the stepper can also be a good way to build your fitness whilst also strengthening the important gluteal muscles. Rowing is another way to keep up your conditioning, but can be aggravating to some whilst not to others, so that will be up to the individual.
A sports physiotherapist will also be able to give you individual advice on cross training to maintain your conditioning and how and when to return to running. A graduated plan for getting back to running will usually involve starting with small amount sand increasing the volume before the speed. The exact advice on how to plan such a program will depend on the intensity of your symptoms and the specific activity you are training for.
To prevent Runner’s Knee, the most important thing to consider is suitable planning of training loads. Increasing loads too quickly, or adding in too many hills or speed sessions without building up to it, can be the most common precursor to ITB problems.
As with most sports, a small amount of strength training can help with both performance and prevention of injury. Exercises targeting the gluteals and general trunk stability, done 2 or 3 times a week, can build strength and endurance, and help control the trunk and pelvis movement over the knee. Stretching may not necessarily prevent Runners Knee, but keeping good flexibility around the hip and thigh will help with your performance.
Correct footwear is really important. Different amounts of support are needed for different people, and the right amount of support can help to control movement about the knee and pelvis by helping the position of the foot as it strikes the ground. A podiatrist may also be able to help, especially with the biomechanical contributions. For some people, custom-made orthotics can be necessary to help control the foot’s positioning.