By Adelaide Women's Physio | August 15, 2019
Runner’s outer knee pain is a common injury. The term used to describe the lateral knee pain is often iliotibial band syndrome (ITBS). Some twelve percent of the running community will experience knee pain felt above the outside of the knee joint. A physiotherapist will need to do an examination of muscles, ligaments and the knee joint. This newsletter will focus on the ITBS.
Where is the Iliotibial Band (ITB)?
The ITB is a thick band of connective tissue that arises at the top of the hip, from the tensor fascia lata and gluteus maximus muscles. It runs down the outer thigh from the pelvis to the shin bone of the lower leg (tibia). The ITB provides lateral stability to the hip and knee joints.
What is Iliotibial Band Syndrome (ITBS)?
The prime cause of ITBS remains debatable. The most accepted theory is when the knee flexes or bends, a tight ITB creates an irritating friction force at the outer femoral condyle, which leads to irritation and pain at the lateral knee. However, current thinking proposes that a layer of fat, with a rich nerve and vascular supply, is compressed between the ITB and outer femoral condyle, causing inflammation and pain. We await further research to confirm this theory.
What causes ITBS?
The classification of ITBS being an overuse injury means training error is often the primary cause of the inflammation and pain. How much you train, how hard you train and how often you train will determine the loading capacity of tissues. When the load on tissues is too great an acute inflammatory response at the outer knee can occur.
Gluteal muscle weakness and poor movement control in the running activity can contribute to further tissue strain. Also if the knee rolls in (valgus) whilst running, greater compression and loading of the ITB at the knee joint will occur. Poor stability at the hip and/or ankle may add to movement control issues around the knee when running.
ITBS Treatment Options with Physiotherapy.
The first option is settling the acute inflammatory response with rest and ice packs. It is important to stop the aggravating activity, such as running, brisk walking or cycling, to allow the healing response to occur. Ice packs to the painful area on the outer knee and thigh can be helpful.
Manual therapy including soft tissue massage, trigger point release, ultrasound, and dry needling may be required to reduce muscle tension in the ITB or quieten areas of pain and inflammation.
When the symptoms have settled, exercising the weak muscle systems efficiently is important. This means your physio will choose exercises for you with progressive, graded loading. These exercises will help to reduce the strain on compromised tissues along the ITB and at the lateral knee when you return to running. The exercises will focus on strengthening core muscles, gluteus maximus, hip abductors (gluteus medius, gluteus minimus and tensor fascia lata) and hip rotators.
Finally, treatment will need to correct movement control in the aggravating activity of running. This can involve movement at the knee, ankle, foot, hip, pelvis and lumbar spine. The physio’s assessment will determine what areas of your body need to be addressed.
Stretching is now not believed to be a reliable, initial treatment approach, as the ITB’s tensile strength is like steel. However, stretching and mobilising the ITBS with a roller may be helpful in self- maintenance, once muscle strength and movement patterns are rehabilitated. A gradual return to running is then advised.
So when pain in the outer knee is debilitating and making it difficult for you to be active, there is hope. ITBS can often be a cause of this lateral knee pain, which must be carefully assessed and then treated according to examination findings. It is good news to realise that this presentation can be effectively treated with a variety of physiotherapy treatment options.