Wednesday, June 20, 2012

Best treatment for "Runners' Knee" aka IT band syndrome, Part 1

IT band syndrome or "runners' knee" is quite common in the athletic community and particularly with runners. Patients often complain of pain on the outside of the thigh or near the outside of the knee while they run or after sitting for a long time (aka the "movieogers' sign).

The "IT" band or iliotibial band is a long stretch of connective tissue that runs from the side of your hip down the side of your knee, anchoring just below the side of the knee cap. It's a very sturdy length of tissue and provides a great deal of stability to your limb particularly during dynamic activities like running and jumping. The gluteus maximus and TFL muscle (tensor fascia lata) attach to the IT band with the TFL located at the very top of where the IT band originates.

Causes of Dysfunction
Tightness of the hip flexors, TFL, relative weakness of the hip external rotators (glutes, eg) and quadriceps (VMO) can contribute to a tight IT band. Hyperextended knees may also cause more stress on the IT band, causing it to be more stiff and painful. Without addressing these regions and correcting the biomechanical and movement faults through specific strengthening, neuromuscular re-education, and flexibility exercises, it is almost meaningless to do things like friction massage or foam rolling, since the heart of the problem has not been gauged out yet...allowing the problem to return quickly.

The treatment approach to IT band syndrome is multi-factorial from a physical therapy perspective. Deep friction massage, rolling on the foam roll, relative rest, and IT band strapping are important mainstays in treating the SYMPTOMS, however, we must first address the aforementioned causes before deciding on what approach would be most suitable. So.....

WWMD? (What Would Maven Do?)
For runners and triathletes in particular, we have to look at a few things with a finer lens.  Running form can be a telltale sign of IT band pain causation, especially for those who run "knock-knee'd".  Does the athlete's foot pronate?  Is an orthosis necessary (you say, orthotic, we say orthosis)? If an athlete bikes with his/her knees turned in, as some have been taught, there is a risk of stressing the IT band unnecessarily.  We always check a person's single and double limb squat, as described by Dr. Chris Powers from USC, and gain a lot of information about how much contribution gluteal weakness may be involved in an athlete's IT band pain.

In addressing a patient's IT band pain symptoms, we have found
Jenny McConnell's IT band taping strategy to be particularly helpful in managing symptoms as well as velcro ITB straps. We usually tape or strap up the IT band prior to strengthening the knee to maximize the effect of the exercises while "quieting" the IT band from interfering with our treatment goals. Sometimes with chronic cases, using therapeutic ultrasound on a higher setting (1.0 MHz, 1.8-2.0 W/cm2) to improve elasticity of the IT band before exercises helps. Having the patient warm-up on a non-pain-provoking cardio machine (bike or elliptical, usually) before we start strengthening activities can also suffice.  

Strengthening the gluteals is an absolute mainstay in treating the IT band.  Period.  Hitting up the glutes often gets overlooked by some rehab professionals continuing to use antiquated knee flexion/extension activities (they are important to include, but only a part of  the solution).  For a complete list of exercises we use at Maven, stay tuned.

Depending on how long the patient has waited to see a medical professional and how willing he/she is to limit the pain-causing activity temporarily, IT band treatment can take a good three to six weeks before symptoms begin to subside and a return to sport protocol can be implemented.  I can tell you from my own experience, the waiting period for an injury to improve is absolute mental torture more than it is physical pain at times. Can I get an AMEN?!

In the meantime, running in the pool, cross-training (including Mavenaction or CrossFit type workouts) at your heart rate in 80-90%+ range over a sustained period of time can be quite beneficial in maintaining your level of fitness for competition or training. 


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