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IT band syndrome and IT band friction syndrome are two common diagnoses that mean the same thing for lateral knee pain.  I know first hand how painful and annoying this type of knee pain can be.  Years ago, I was on a run two days before a big race when I started feeling a slight pain along the outside of my left knee.  I figured it would go away.  But within five minutes it had progressed to a very sharp pain, like a knife was being jabbed into the outside of my knee every time my foot hit the ground.  I had to stop and walk home.  Over the next two days, my knee felt tight & sore and stairs remained painful to walk down.  After a few days of rest I tried running again but the pain returned, this time more quickly.  A trip to the knee doc and an MRI only intensified my frustration.  He said there was nothing showing up in the MRI.  And his advice – my blood pressure still goes up even thinking about this –  ”I don’t see anything wrong with your knee.  Maybe you just shouldn’t run so much.  Do you like biking?”  WHAT!!!!!?????  Are you kidding me!?  I couldn’t believe THAT was his answer.  Fortunately, I was half way through the Physical Therapy program and eventually figured out that I had IT band syndrome.  So I’m always very excited when I can prevent other people from having that same frustrating experience.

Like I said in part 1, there are always exceptions to types of knee pain.  Not everyone will have the exact same intensity of pain that I had.  Also, there are other causes of lateral knee pain (see disclaimer below).  But for runners who haven’t fallen or had some other traumatic knee injury, IT band syndrome is usually the problem.  Below is an explanation, beginning with a self-assessment to help you better understand what’s going on.

Start by standing in front of a mirror with shorts on so you can see our knees.  Stand relaxed and look at your kneecaps.  Do you see one or both oriented somewhat inward instead of straight ahead?  In an extreme case, a person might even notice their knees are closer together than their feet. Next, you’re going to tighten your glutes, AKA: squeeze your butt muscles (not with your hands, I actually had a guy do that once) – watch what your knees do – they’ll slightly rotate laterally to the point where your knee caps are now facing more forward.  Tighten and relax your glutes a few times and you’ll see your knees rotating in and out.  As you’re tightening your glutes you’re externally rotating your hip, which directly affects your knee orientation.  If your knees face inward when you stand relaxed, then the hip external rotator muscles that should be maintaining the alignment of your hips have become weakened.  This leads to knee pain.  So when you need your muscles to support your hips in the proper position while running (which is much more demanding than standing), they eventually fatigue to the point where they can no longer do their job.  This is why your knee pain doesn’t set in until you’ve run a few miles.  Over time, the distance you could run would lessen, stairs would become more painful and eventually you’d have knee pain all the time.

Side view of the knee

Side view of the knee

What’s causing my knee pain if the problem is in my hip?  The IT band starts at the hip as a wide tendon where it attaches to the hip bone (Ilium), the glutes and a small muscle called the tensor facia lata (TFL).  It runs down the outside of your thigh to just below the knee, attaching to the tibia.  This is why it’s called the “IT band.”  It connects the ilium to the tibia.  As the IT band approaches the knee, it rubs against the lateral condyle of the femur (see small image).  I like to use the car front-end alignment analogy to explain this:  If the alignment is off in a car, the tires wear more quickly.  The problem is not the tires, it’s the parts that align the tires.  In our knees, the IT band pain is the same as the worn tires, just a symptom of the root problem.

IT Band

IT Band

How is this related to running?  Think of your knees as simple hinge joints, similar to a door hinge.  They can only go forward and back.  Our kneecaps point in the direction that the hinge is facing.  So if you’re running forward you want your knees to flex straight forward and back, not at an angle.  If your knee is rotated inward, the friction of the IT band on the lateral condyle is greater and things become irritated, especially during repetitive movements like running.  When you see runner’s with their feet kicking out to the sides when they push off, you’re seeing the poor biomechanics of hip internal rotation in action.  They probably have painful knees.

How did this muscle weakness happen?  The short answer is sitting.  When we sit for hours at a time, the muscles are not active.  The use-it-or-lose-it philosophy rings very true here.  Over time, the muscles become more accustomed to being at rest and lose their strength.  I’ve noticed a trend when I talk to people about this subject.  The knee pain usually starts after about 5-6 years of working at a desk job.  Unfortunately, you can count graduate school as a sit-down job.  Incidentally, sit-stand work stations are becoming more popular and I strongly encourage people to consider those if they’re stuck behind a desk work.

How do I fix it?  The permanent fix is to re-strengthen the hip external rotators.  I’ll describe a few exercises below.  In the mean time, there are a couple of things to try that might give some temporary relief.

You can never go wrong with putting ice on the painful area.  This will help decrease any swelling and pain.

Many people try using a foam roller on their IT bands.  That works, but it can be quite uncomfortable and not everyone has positive results.  In the clinic, I do a manual technique called the IT band release.  The closest thing I can describe that a person can do on their own legs is to work up and down the outside of your leg (4-5 times) pressing down and twisting, similar to how you’d open a medication bottle.  You do this WITHOUT any massage cream or lotion.  The idea is to get the layers of fascia, muscle and connective tissue to move independently of each other under the skin. It will feel like a dull ache as you apply pressure.  You can have another person do this for you as you lay on your side, just be careful because your leg will be very sensitive the first few times.  If done correctly, when you stand up and walk around after, your knees should feel lighter and easier to move.  This usually carries over to running.

Exercises: A person will benefit from any exercise that involves hip extension.  I encourage people to avoid machines and do functional exercises.  Functional exercises are more dynamic, require balance and often include the core.  That being said, some functional exercises will be too advanced for someone with significant hip imbalances.  Below are some good basic exercises to start off with.

Standing hip Extension:  Start with a thera-band or cable machine passed under your foot and the handle or loop around your heel.  Stand tall with knees slightly bent.  Without tipping forward or bending your knee, extend your leg backward 1-2 feet (don’t strain to achieve more movement).  Hold for 1 second and SLOWLY return to start.  Try to stay balanced on one foot the entire time as you do 12-15 repetitions.  You should feel your low back, glutes and hamstrings working.  Repeat other side.  Alternate sides, doing 2-3 sets each side.

Standing Hip Extension

Standing Hip Extension

Hamstring curl on a ball:  Lay on your back with heels on an exercise ball and arms out to the side for balance.  Lift your hips up so your body is in a straight line through your knees, hips and shoulders.  Bend your knees and roll the ball toward you with your feet until your knees are bent to about 90 degrees.  Keep your knees, hips and shoulders aligned the entire time.  At this point, you may feel like most of your weight is on your shoulders and upper back.  SLOWLY straighten your knees returning to the start position.  Repeat 12 times, 2-3 sets.  If you have trouble lifting your hips all the way, raise them as high as you can and avoid touching the floor when you straighten your knees.

Hamstring Curl On A Ball

Hamstring Curl On A Ball

Ball squat:  Place an exercise ball against a wall and lean against it with your low back.  Feet should be ~12-16 inches out in front of your hips.  Keeping your back straight and your weight on your heels, SLOWLY squat down as far as you’re comfortable, not letting your knees bend past 90 degrees.  If your knees go out beyond your toes, move your feet forward so knees are above the middle of your foot.  Push through your heels and straighten your knees.  Do not bend forward as you press up and do not let your knees quickly snap straight.  Repeat 12-15 times 2-3 sets.

Ball Squat

Ball Squat

Step Up:  A small weight (3-5#) is helpful in this exercise.  Start with the weight in your right hand and your right foot on a 5-8 inch step.  Step up on the right foot and simultaneously raise the weight straight up and lift your LEFT knee to hip height (as if a string was attached from your right elbow to your left knee).  Hold for 1 second.  Lower back down.  Repeat 12 times.  Switch the weight to left hand, place your left foot on the step and repeat.  Alternate sides for 2-3 sets.

Step Up

Step Up

In the next knee pain post I’ll be talking about anterior knee pain.  The type of pain that feels like it’s under your knee cap or just above or below the knee.

Have you experienced this type of knee pain? Has this post been helpful? Feel free to ask specific questions in the comment area!

Please let me know if any of the exercise descriptions are unclear and I’ll try to fix it.

***This blog is intended for information purposes only.  It is not intended to diagnose or treat any injury.  Please consult with your doctor or physical therapist if you have any knee pain.  Please consult your doctor or physical therapist prior to starting any exercises or treatment plan on yourself or others.

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I think when most people hear the words “put ice on that” it carries about the same weight as “drive safely”- in one ear out the other.  I have many patients with injuries where icing is appropriate.  When asked how many times they have iced their injury since I saw them last, they quickly divert their gaze to the floor and uncomfortably begin the report of why they didn’t have time or forgot.  I can definitely identify with the lack of time excuse, but if you consider the amount of time put into training, an additional investment of 15-20 minutes is worth it when you consider that one possible alternative is not being able to run at all.  This is especially true if the involuntary down time causes you to miss a race that you’ve already paid for.

Last week I had to do part of a run on a treadmill.  I normally try to avoid treadmills as much as possible but the roads were covered in snow and my training plan had me incorporating some long intervals into my work out.  I figured the treadmill would at least provide consistent footing.  About 15 min after finishing my workout, I started noticing that the ball of my right foot was becoming more painful.  My left calf was also starting to feel irritated as well.  Citing the ‘lack of time’ excuse, I didn’t ice these painful areas that day.  The next morning when I first stood up I could barely put pressure on my right foot and my left calf was so tight that it was causing heel pain.  Throughout that day, I was able to put ice on the ball of my foot a couple of times.  The discomfort decreased but never went away.  I managed to get through my run for that day without an issue, but by the time I got home a significant amount of pain had returned to the ball of my foot and calf.

ice bath

Instead of trying to put ice packs on all the painful areas I decided to hit everything at once with an ice bath.  I filled a 5 gallon bucket about 3/4 full with cold water and stuck my feet in.  Once over the initial shock of the cold water from the tap, I started dumping snow (since this is currently an unlimited resource at my house) into the bucket, filling it to the top.  Anyone wearing a shoe larger than men’s 10 will not comfortably be able to use a 5 gallon bucket, I could just barely keep my feet flat and the water only covered about 2/3 of my calf.  Don’t worry about trying to push the ice/snow down to the bottom, cold water sinks and you’ll quickly feel the colder water hitting your feet.

There are several progressive sensations that you should experience with cryotherapy (ice packs included).  The first is obviously cold, however adding the ice/snow after your feet are in the water makes this stage much more bearable.  The second sensation is going to be an aching/burning type of pain…a moderate ache that’s fairly uncomfortable sets in to the feet first, then the calves.  It’s important to remember that you don’t get the full physiologic benefit until after this stage, so try your best to tough it out.  After about 10 minutes, this passes as your feet/ankles/calves begin to feel numb.  The general recommendation for cryotherapy to reduce pain and swelling is 15-20 minutes.  Remember, more is not better, beyond 20 minutes there is the risk of frostbite and there’s an opposite effect of increased blood flow which can worsen the swelling.  I make sure I’m in a situation where it’s not necessary for me to walk for another 10-15 minutes after taking my feet out of the water…unless my house was on fire, I don’t think I could anyway.  I elevate my feet and let them regain sensation for about 10 minutes and the feeling to them has usually fully returned within 20-30 minutes.

The next morning, as I stood up anticipating pain, there was none at all!  Not only was the pain gone, as an added bonus my lower legs and feet felt much better overall!  Even after my 18 mile run last weekend, the pain in the ball of my foot did not return.  However, just for preventative measures I decided to do the ice bath right after I got home.  The whole process of soaking my feet/legs in ice water has become easier each time I’ve done it.

Small aches and pains can usually be stopped with icing before they become larger problems.  If icing doesn’t seem to be helping after several applications, there may be a larger underlying problem, that’s when you may want to have it evaluated by someone.

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