ITB - is Friction really the problem?

With a lot of people finishing off their training programmes for the Comrades Marathon over the past few weeks, we've seen more knee pain in a month than over the last year!! One of the most common presentations is pain located over the outside of the knee. Runners may be able to run through the pain initially, but with increased mileage and time on the legs, the pain can become so severe that running is no longer possible.

Sound familiar? Many runners will diagnose their own lateral knee pain as ITBFS, or Ilio Tibial Band Friction Syndrome. But what is really going on - is this condition really caused by friction?

The ITB is a structure that has it's origin around the pelvic rim, starting as the tenson fascia lata (TFL) muscle and running along the outside of the thigh to attach just below the knee. The common perception is that the ITB is a band that "frictions" or snaps over the bony part of the outside of the knee (lateral condyle) as the knee flexes and extends during running. In reality however, the ITB is bound down along the length of the femur via an intramuscular septum (membrane), making excessive forward and backward movement of this band impossible. The impression that the ITB slides forwards and backwards is actually caused by a change in the tension of the anterior and the posterior fibers of the structure at various angles of knee flexion. Between the ITB and the the lateral condyle of the femur is a highly vascularised and innervated fat layer which separates the ITB from the underlying bone. When considering the anatomy and biomechanics of the knee, it is therefore more likely that this tissue becomes irritated and inflamed, due to increased compression, that will eventually result in pain.

When assessing patients with lateral knee pain, we find that in most cases there is an adduction (or falling in) of the knee during the stance (weight bearing) phase of running. This can be caused by a number of biomechanical factors such as dropped foot arches, poor hip/femur control, anatomical variances such as genu valgus (knock knees), incorrect footwear or poor running technique.

So how is this condition treated? Firstly, you need to see an experienced physiotherapist. Remember that there are multiple reasons why runners get knee pain, and the right diagnosis is vital to correctly guide your treatment. If the ITB and underlying structures are confirmed as the source of your pain, you should try to reduce inflammation in the tissue. The best scenario is to address the condition early - the fact is that if you ignore the symptoms, pain will eventually stop you from running. More often than not a period of rest from running is required, especially if the pain is present at rest or starts early in any attempted run. This can be very stressful for runners, especially if there is a race just around the corner!! If weak hip muscles is a problem and pain only sets in at a specific distance into the run when the hip muscles start to fatigue, the athlete should be able to continue running shorter distances, but never into pain. Ice and anti-inflammatory medication is useful in reducing inflammation. Kinesiology taping methods may also be useful in lifting the superficial layer of soft tissue to allow lymphatic drainage of the underlying swelling. You may be able to continue doing other cardiovascular exercises such as cycling if that does not cause any pain.

Secondly, an indepth biomechanical assessment is required to identify any predisposing factors. This should include a running analysis (which should also look at footwear), as well as a full physical assessment to identify weak and/or shortened musculature. Strengthening of the core and gluteal muscles is extremely effective in resolving this condition, but strengthening takes time to achieve, so there is no real quick fix. Orthotics may be useful in runners who have very flat foot arches. Manual soft tissue release, as well as foam rolling and stretching will also help to improve the tissue length if it is found to be tight. If running cannot be avoided eg. if symptoms start very close to a race, symptomatic relief is as much as you can hope for.


- ADDRESS THE ISSUE EARLY - don't wait until a couple of weeks before a race as your chances of recovery in such a short space of time is minimal

- DO NOT RUN INTO PAIN - It WILL get worse if you do

- GET STRONG - no amount of stretching or foam rolling will make your pain disappear - strength will

- GET AN EXPERT ASSESSMENT - a wrong diagnosis may cause even more pain or time off running

Our therapists are very experienced in treating knee pain in runners. If the symptoms we described here sound familiar, or if you are unsure of your diagnosis, CONTACT US TODAY! We are here to get you better!!

P.S. - We will be keeping track of all our patient's progress during the Comrades Marathon this weekend - GOOD LUCK ON 10 JUNE 2018!!

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