Highlights

• Runner's knee, also known as Iliotibial Band Syndrome (ITBS), is a common issue among runners caused by the friction of the iliotibial band against the femur, leading to inflammation and pain.
• Treatment strategies for runner's knee encompass a holistic approach, including strengthening exercises, stretching, cross-training, soft-tissue techniques, and a gradual return to running while monitoring load.
• Strengthening exercises targeting the hip abductor muscles are commonly prescribed for ITBS rehabilitation, their effectiveness remains uncertain, and the focus should shift towards neuromuscular control and strength endurance rather than maximum strength.
• Stretching and Flexibility Although stretching can temporarily reduce stiffness and neuromuscular activity in the ITB, its long-term effects on tendon mechanical properties are minimal, emphasising the importance of incorporating stretching into regular routines for sustained benefits.
• Gradual Return to Running and Load Monitoring After addressing pain and strengthening muscles, individuals should reintroduce running gradually, starting with short, gentle runs on flat terrain and listening to their body's signals to avoid exacerbating the injury and promote a safe return to running.

Our bodies require more care and consideration as we age, particularly when engaging in physically demanding activities like running. Runner's knee, also known as Iliotibial Band Syndrome (ITBS), is a common issue that runners encounter.

Common consensus would suggest that ITBS, occurs when the iliotibial band rubs against the Iliotibial bursa, irritating it.

The iliotibial band is a tendon of the Tensor Fascia Latae (TFL) muscle that serves as a common tendon for the gluteus maximus (GMax) and TFL muscles. It transmits their contractile forces to various insertions on the distal femur, patella, joint capsule of the knee, and tibia.

In addition to GMax and TFL, the ITB also has tendinous components from the gluteus medius (GMed), biceps femoris, and vastus laterals muscles that insert into it. Due to compression against the lower end of the thigh (femur) bone, this sac becomes swollen, leading to friction, inflammation, and pain.

It is a frequent injury caused by repeatedly bending the knee during running, hiking, and walking long distances. In this blog, we will delve into the causes of a runner's knee and provide expert advice on preventing and treating it.

Understanding Runner's Knee

Recreational running has become increasingly popular since the 1970s, mainly because it's been proven time and time again that it has a positive impact on health and is relatively inexpensive (so long as you’re not buying the latest gear that costs a few hundred £).

Unfortunately, running also carries a significant risk of injury, ranging from 24% to 85%. ITBS is the second most common cause of pain in running injuries, accounting for around 10% of running-related injuries.

Symptoms usually occur during exercise after a certain amount of time or distance.

ITBS causes a sharp or burning pain in the lateral femoral epicondyle (outside and above the knee) area.
As I mentioned before, ITBS is believed to be caused by the friction of the IT band on the lateral femoral condyle when the knee is bent.

Other theories exist, though, suggesting that it could be due to fat compression near the IT band's attachment at the knee and inflammation of the IT band bursa.

The friction theory suggests that repetitive impingement at around 30 degrees of knee flexion leads to inflammation and pain.

Another theory involves fat compression between the IT band and the femoral condyle. However, in cadaver studies, the presence of the Iliotibial bursa varies between people, making this type of cause questionable.

Some studies have even shown that the lateral femoral epicondyle causes tendon irritation of the ITB.
Imaging-based research has supported this, showing the anterior-posterior movement of the iliotibial band (ITB) relative to the lateral femur during knee flexion and extension.

Fibrous strands firmly attach the ITB to the lateral femoral condyle, preventing shearing between the ITB and bone in the anterior-to-posterior direction. It is believed that this excessive tension in the ITB can compress underlying fat tissue or the bursae, ultimately causing inflammation and pain.

Although oedema between the ITB and the lateral femoral condyle is more typically seen than pathological alterations of the ITB itself, no direct and robust evidence supports the compression hypothesis.

This is still a hot topic, but there appears to be no clear indication as to why it occurs. However, some of these theories lend plausibility and are relatively linked enough that the exact cause isn't too much of a cause for concern.

https://my.clevelandclinic.org/health/diseases/21967-iliotibial-band-syndrome

Effective Treatments for Runner's Knee:

There are many different ways to treat runner's knee. Some are easy to do yourself, and some may require expert advice. The good news is that they are generally relatively straightforward, and you don't need fancy equipment.

Here are five things you can do to treat runner's knee

1. Strengthening Exercises:

Research on strength training as a treatment for iliotibial band syndrome (ITBS) in runners is limited, with little high-quality evidence. Recent studies have compared conventional ITBS rehab to physiotherapy focusing on strength training and stretching but found no significant difference between the two approaches.

The idea behind strengthening the hip abductor muscles is that weakness in the gluteus medius (GMed) can lead to increased tensor fasciae lata (TFL) activity, worsening ITB tension. However, researchers have found no abnormal TFL activation in ITBS patients during running, but they did observe reduced fatigue resistance in the GMed.

To address the GMed's fatigue resistance, more than heavy and slow strength training exercises may be needed, and just building maximum strength may not fix abnormal running mechanics. Targeting the GMed alone is also tricky because hip abductor strength training can affect the TFL and gluteus maximus (GMax), increasing forces on the ITB.

Although strength training may increase tendon stiffness, which helps prevent injury, it can also limit the tendon's ability to absorb shock and increase the risk of irritation under the ITB. This is why focusing on neuromuscular control and strength endurance, rather than just maximum strength, is crucial to avoid unwanted side effects.

While hip abductor strengthening is often included in ITBS rehab, its effectiveness is unclear. The current evidence doesn't strongly support the idea of abnormal TFL activation in ITBS patients, and building hip abductor strength alone may not address underlying issues, like abnormal running mechanics or pelvic drop. Moreover, strength training may have unintended consequences, such as increased stiffness in the ITB and inadvertent strengthening of other muscles.

Therefore, while strong hip abductor muscles are essential for running stability, the benefits of strength training in ITBS rehab need to be carefully weighed against the potential risks and uncertainties.

Incorporating hip muscle exercises through strength training can benefit a runner's knee rehab. However, focusing on neuromuscular control and strength endurance is essential to avoid adverse side effects rather than maximum strength. Following strength training with measures to reduce muscle tone can also help prevent unwanted impacts. By taking these steps, runners can work towards regaining their strength and supporting their knee's recovery.

Strength training is crucial for endurance athletes who suffer from a runner's knee. According to available research, adding strength training to an endurance athlete's routine can improve their economy, muscle power, and overall performance. However, the effectiveness of the strength training program depends on several factors, such as the program's duration, the athlete's current strength level, and the specific exercises used, including their velocity and loads.

For endurance athletes who lack strength or neuromuscular efficiency, a general maximal-strength-oriented program may be the most beneficial initially for enhancing their maximal force, power, and reactive-strength capabilities. Conversely, endurance athletes with already high-force capabilities may benefit more from specific explosive and reactive-strength training to further improve their performance.

2. Stretching and Flexibility:

Stretching can help to reduce stiffness and neuromuscular activity in the iliotibial band (ITB) muscle-tendon unit, but the effects are usually temporary and tend to disappear within 30 minutes.

Although more research is required to investigate the long-term effects of stretching on ITB, it is unlikely that intermittent stretching during rehabilitation will result in significant changes.

Instead, stretching can increase stretch tolerance with minimal reductions in muscle stiffness. This can help to reduce muscle tone, especially after performing exercises that strengthen the hip and thigh muscles.

To achieve lasting effects, it is recommended to perform static stretches for the ITB for at least 3 minutes, which can be achieved by doing three sets of 1-minute stretching sessions. Regularly incorporating stretching into your routine can optimise the benefits of stretching for reducing muscle tone and overall rehabilitation efforts.

3. Cross-Training:

When runners get a runner's knee, they often worry about how it will affect their fitness. It's understandable because running can be time-consuming and expensive, and going from setting personal records to being unable to run can mess with your head and motivation, causing many people to give up. But being injured can have its advantages. When you train for a competition, you can get tunnel vision and focus solely on running, harming your overall athletic development.

Taking a break can allow you to step back and work on other areas for improvement.
For example, running is tough on your knees and joints, but alternatives, like cycling or swimming, can help you maintain or build your aerobic capacity while your knee recovers. You can still train in Zone 2/ Zone 3 and work towards your goals.

This is also a great time to work on areas that have bugged you for a while. If you experience calf tightening when running, now is the perfect time to build strength-endurance to prevent it from happening. If you experience lower back pain when running, now is the time to work on your core and back strength.

Studies have also shown that exercise, especially cardio, boosts blood flow to damaged tissues, helping them heal more quickly. With a good nutrition plan, your recovery can be even faster.

4. Soft-Tissue Techniques

Soft-tissue techniques can help you feel better and be more flexible if you're recovering from a runner's knee injury. Massages can be effective because you can customise them to your liking. You can ask for a gentle touch, moderate pressure, or specific techniques to help with your problem areas.

Massaging your TFL, outer quad, and gluteal muscles can be especially helpful for a runner's knee. Massages can help with muscle tension and increase blood flow and overall muscle function.

If you want to get the most out of your recovery, you should also warm up before you exercise, cool down afterwards, do some strength training for your lower body, and get enough rest. By taking a holistic approach to your recovery, you'll be able to get back to your old self in no time.

5. Gradual Return to Running and load monitoring:

Once your runner's knee pain starts to fade and you've worked on building up the muscles around your knee, it's time to start adding running back into your routine slowly but surely. Begin with short, easy runs on flat terrain and gradually increase the time and intensity as your body permits.

Paying attention to how your body feels during this phase is crucial. If you feel any pain or discomfort in the affected area above a 4/10 (where 10 is the worst pain you can imagine), stop immediately and reassess.

If you try to push through the pain, you could end up making your injury worse and delaying your healing time. Feeling a little discomfort is alright, but don't try to do too much too early on. Instead, take it easy and be mindful, letting your body adjust slowly to running again.

Remember, the goal isn't to return to your old running routine as fast as possible but to build up your strength and resilience while minimising the risk of further injury. By paying attention to your body and gradually increasing your running workload, you can get back to running safely and sustainably.

So listen to your body and gradually ramp up your running, and you'll be back to your usual routine in no time!