With the Spring running season coming to an end, and some time off in the near future for runners to hit the gym and work on weaknesses, there is no better time to talk about one of the most common running injuries.
Personally, I have suffered with ITB syndrome so I sympathise with any readers who have experienced it. If you are lucky enough to have avoided it thus far, take it from me, it’s a brutal condition and can leave you frustrated and on the sidelines for months. For those who are unaware – it presents as pain on the outside of the knee and tends to hurt during or after a run.
Please note, I have mentioned runners in the title and in my introduction but be aware that it is a condition which can affect all endurance athletes – anyone who is constantly putting load through the knee is vulnerable.
In clinic we see a lot of patients with ITB syndrome and have a lot of positive results, helping a variety of athletes get out of pain and back to activity in a safe and controlled manner. The biggest and most common barrier is actually how to manage the condition when you are pain free, how to control the intensity and load when returning to running as a lot of people naturally assume “I am out of pain therefore I am a able to start loading as heavily as I was before I was injured” and this is where recurring ITB syndrome comes into play.
Hence why I want to share some insight with you today, to help clarify the condition, how to treat it, why it’s important to gradually increase load and some preventative tips.
What Actually Is ITB Syndrome?
First let’s start off by grazing over the IT band (Iliotibial band). It is a thick, strong band of connective tissue which starts at the top of the thigh (the bony prominence on the outside of the hip) and down to the outside of the knee.
As I said earlier, pain is mostly felt on the attachment point which lies on the outside of the knee. How? Well excessive friction and compression of the attachment causes irritation and leads to pain. This is a result of too much load going through the outside of the knee or too much friction during the knee bending and straightening movement. That said, the excessive friction explanation is slowly being edged out of the current research with the weight leaning more toward compression and over load.
Why Is It So Common With Runners?
This is the million dollar question, and it’s important for us as practitioners and you as patients to understand that it is probably a combination of factors, very rarely is it down to one silver bullet.
It’s more common with runners than other athletes because of the repetitive strain and load that running demands, thousands of steps are taken during a run with more force than normal going through the joints of the lower limbs. So naturally you are more likely to have ITB irritation if you run a lot, combine that with other contributing factors such as:
- Sudden increase in weekly distance (jumping from 5k a week to 25k a week)
- Poor recovery (Not resting enough in between sessions, I’d like to point out that rest is actually part of your training).
- Increase in hills and speed sessions (this causes an overload on the ITB and the outside of the knee).
- Weakness in glutes and hips (If the muscles that attach to the top of the ITB are overworked and tight due to weakness they can pull on the top of the ITB. This then effects mechanics of your run and how the ITB acts in correlation with your knee at the attachment point).
- Running mechanics (if your knees drive inwards as you run, causing your feet to run on a same centre line as one another – this puts a large amount of pressure, load and compression on the outside of the knee).
- Lack of strength training (Having weak hamstrings, glutes, quads not only leaves joints and surrounding tissue vulnerable but effects running mechanics).
- Returning from injury too soon (When the pain has gone this does not mean the problem is solved).
Common Symptoms
The symptoms tend to start off between light and moderate and progress the more you push through them. Often they start in a different area, and can present as tightness in the glute or hip.
Most common symptoms include:
- Pain in the outside of the knee
- Pain free at the start of a run but begins to get more aggressive as a the run goes on (usually after the same amount of time or distance).
- Feels worse downhill (when you are decelerating)
- The pain feels like a sharp stabbing sensation
- Tightness sensation along the outside of the thigh
If you were to only take one thing from this piece I would put great emphasis on this. When you start to feel the pain, stop immediately. From personal experience and from the patients who I have treated with ITB, it starts off as a gentle niggle and progressively gets worse, but by the time you feel the need to stop the damage has already been done. The earlier you stop means the less damage done and the quicker your recovery will be.
This too, goes for most running injuries, but there is a huge amount of time on the sidelines that is saved by stopping early and getting that ‘niggle’ on the outside of the knee checked out.
HOW IS ITB SYNDROME TREATED?
As I mentioned earlier, it is very rare for there to be one determining factor causing your ITB pain. With multiple factors adding in their 2 cents, it can be a complex condition to treat and rehabilitate. That being said, one thing I do not advise is pure rest. To avoid the vicious cycle of “Injury – Rest – Pain free – Run – Re injury.” It is best to adapt your load to something that causes zero aggravation. This step by step guide is how I have had some really positive results treating ITB syndrome:
- Stop running and/or any aggravating activity. Let the inflammation calm down.
2. A progressive strengthening program
This will usually look like a lot of glute, hamstring and quadriceps strengthening – these exercises will need to be tailored to you specifically, unfortunately it is not a case of one treats all and its dependant on a number of individual factors (such as muscular imbalances, severity of pain, recovery, healing ability).
- Soft tissue and mobility work
It is important to loosen up any tight areas. The chances are that there are compensations playing a role in your pain, therefore we need to work on relaxing over active muscles and getting more mobility in tight joints.
- Running assessment
This is where we understand what is happening when you run, to tell us more of a story about what is compensating to cause that load being placed on the outside of your knee. You might be wondering, shouldn’t this be done at the very start, and yes it would make everyone’s life easier if we could, however there is every chance that whilst you’re in pain you may run differently, to guard the pain, therefore we could actually pick up some false readings and leave us treating the wrong areas.
- More progressive strength work + plyometric training
Once the running assessment is done we then further tune the strength work to ensure that it is specific to helping your running gait. Adding in plyometric training at the same time to teach your knee to land, control and produce force quickly, which is what you do every step you take whilst running.
HOW TO GET BACK INTO RUNNING?
I could have put this as number 6 in the previous section but it is so important that I feel it deserves its own sub heading. Please bear in mind. This is probably the toughest part from a patient’s perspective because you will feel like you can do more than you are doing.
However, it is like walking a tight rope in a way, because if you do not do enough you will not build the load, but if you do too much you run the risk of re-irritation.
Therefore it’s important to gradually increase your load week by week, in a safe and controlled manor to reduce any backward steps.
Things I believe to make a huge difference is keeping track of any sensation you get during or after a run, adding in run:walk strategies, avoiding inclines and declines, running at a slow pace, gradually introducing speed work.
This is the most important and the most vulnerable stage.
IS ITB SYNDROME PREVENTABLE?
YES, absolutely it is preventable.
What I have found, is that most cases of ITB syndrome occur when ITB cannot withstand and tolerate the load that runners put through it, therefore the main ways to prevent it are:
- Increase your load gradually (10% per week is a good rule of thumb) and this applies to preventing all injuries.
- Strength train – focus on single leg variations of exercises such as: Bulgerain split squats, Romanian deadlifts, bridging and calf raises.
- Plyometrics – every step you take when running is a land and a hop technically, therefore having strength is one thing, but not being able to use that strength in an explosive and reactive way is going to overload the tissue.
- Wearing the correct footwear – A lot of people who experience ITB pain have done so in shoes they have worn for a long time, so be mindful of how long you have had your current shoes for and how many miles you have done in them. A general and I mean very general rule of thumb is between 300-500 miles, however different types (slow, tempo, race, every day) of shoes do vary, but I won’t get into that now as that could be a whole blog post in itself. That being said, when buying new shoes be sure to gradually fade them in to your routine (those running 3-5 times a week) to prevent the ITB becoming irritated through an adaptation overload.
- Warming up correctly and activating the glute medius, hip flexors, soleus and adductors – these muscles tend to need waking up before a run.
- Having a gait analysis – this gives you the opportunity to have your running gait looked at, to see if there is something that may need tweaking. Prevention is better than cure after all.
- Sleep –I thought I would save this one until last because I’ll be honest, you can do all the strength work, plyometrics, eat well, watch your training load, wear the correct shoes and take every supplement under the sun. If you do not sleep enough you have a higher chance of getting injured.
TO FINISH UP
I hope you have learned a thing or two reading this, I hope it has raised your awareness of certain symptoms, the causes behind the condition, why runners suffer more than other athletes, treating methods and most importantly some hacks to prevent it.
To summarise, ITB syndrome can be a bit of handful and as a keen runner I know the pain that comes with being on the sidelines and not being able to do what you love, work towards your goals and keep fit and active. That being said I want to end on a positive note and ensure you all that ITB syndrome is preventable and with early assessment and treatment it is also manageable.
Jack Underwood
Sports Therapist