Runner’s Knee (ITB Friction Syndrome), a rehabilitation perspective

Before I explain how I rehab & treat this injury I wanted to get three things off my chest that really piss me off;

1.      The myth that you can 'stretch' the ITB, it is non-contractile, meaning it is unable to shorten or lengthen like muscle tissue, so you cannot stretch it.

2.      Foam Rolling the ITB, causes no immediate effect, apart from absolute misery & ungodly pain, leading to a release of cortisol in your blood that causes stress and forces you to contract muscles as a response.

3.      'Massage therapists’ who think that beating someone’s ITB up will reduce the tension running through it.

What is it?

An injury which presents on the outside of the knee, it tends to be more common in runners, hence the nickname ‘Runners’ knee).

Functional anatomy

The Ilio-tibial tract originates at the ilium feeding into the Tensor Fascia Lata (TFL) running down the leg toward the outside of the knee, before inserting into the outer aspect of the Tibia.

The ITB is a non-contractile fibrous (thickened) band of taut fascia (fascia= connective tissue that links muscles together into functional slings & separates them in to working compartments).

How the ITB work in biomechanics of running

In running, the ITB works to support the lateral sling system, providing stability to the knee joint during flexion (knee bent) and extension (knee straight).

When the knee is in extension you can see that the ITB sits slightly in front of the bulbous bony feature on the outside of the knee joint known as ‘lateral femoral condyle’.

During running gait when the knee achieves 30 degrees of flexion the ITB will pass over the femoral condyle, rubbing against it, this is how Runner’s knee received the term ‘friction syndrome’. Repetitive frictions will cause rubbing leading to inflammation & discomfort around the outside of the knee.

 How to Diagnose

·        Increased running (especially downhill)

·        Pain may not present immediately, it may become worse after a certain distance, it will however become too painful to continue

·         Pain is not present following relative rest yet upon restarting running activities the symptoms return

·         Signs & Symptoms

·         Localized pain to outside of knee joint (approximately 3cm above the joint line)

·         Minor swelling which may commute to the front outside of the knee

·         Applying a compressive force with the thumb to the area, in combination with knee flexion and extension (to 30 degrees) replicates the symptoms

·         Positive Obers test

The ITB is unable to shorten or lengthen like muscle tissue: Excessive tension must therefore be produced by muscles that connect to it via fascial trains.

 

TFL- Has similar functions to the glute medius but poor commitment to flexibility of the TFL (or lack of understanding) & too much training of the anterior chain (front of body) forces up-regulation of the TFL & excessive dominance over the gluteal group. 

It becomes actively shortened, leading to a tilting forward of the pelvis, significantly increasing tension on the ITB.

Quadriceps (Vastus Lateralis)- This outer quad feeds under the ITB, in comparison to the inner quad (Vastus Medialis) it becomes over developed, shortened & neutrally overactive, lending to the development of many trigger points that restrict movement in the ITB and contribute to symptoms.

Glute maximus- Its deep fibres contribute to local stabilization of the Sacro-iliac joint; however it is the superficial fibres we are interested in; A flat lumbar spine (or tailbone tucked under) will cause the glute max to be held in an actively shortened, up-regulated position, again potentially contributing to the tension through the band.

Biceps Femoris- Outer hamstring, feeds via fascia into back of the ITB, if this muscle becomes shortened, it may contribute to symptoms.

Muscle summary; we can assume that the following factors will contribute to excessive tension of the ITB & the presentation of symptoms;

• Lack of knowledge & poor training
• Up-regulation of muscles that attach into the ITB due to over-use
• Active shortening of muscles that attach into the ITB due to poor posture & adherence to flexibility
• The Development of trigger points that act like roadblocks within muscle fibres creating excessive tension, caused by poor adherence to fascial release

Rehabilitation

• Remove aggravating factors such as running provide an alternate means of CV such as swimming or cross trainer until symptoms subside
• Allow time for rest, ice if required
• General Massage + Frictions- around the insertion of the ITB on the femoral condyle, to promote breakdown of any thickened scar tissue around the knee 
•  Application of advanced soft tissue therapy techniques including soft tissue release, muscle energy techniques to over-active muscles 
•  Inhibit over-active muscles through self-administered trigger pointing with a tennis ball/ Hockey ball: (TFL, Vastus Lateralis, Glute Max)   
• Flexibility of all muscles mentioned above if it is confirmed through functional movement screening & coaching that they are in a shortened state 
• Activation of Glute medius, medial hamstrings, VMO and Short adductors
• Application of rock/ kinesio-taping to muscle tissue or fascia to facilitate movement  

For further advice on soft tissues therapy/ rehabilitation programming or to book in for an appointment, please do not hesitate to contact me directly through my Twitter of FB page. 

Primal Movement Solutions- Who are we & how can we add value to your sport/ daily living activities

Primal Movement Solutions (website under maintenance) delivers remedial massage & advanced soft tissue therapy techniques in combination with quality bespoke rehabilitation programs to it clients. We operate a mobile service in Surrey/ Hants & Berks

Analogy
We like to use the example that "most people treat their bodies like their cars, they only get them fixed once it has broken down". Its a reactive response rather than proactive.
You only get one body, which has to carry you on this earth for many years, it needs to be serviced regularly otherwise it will develop many problems & eventually fail. In most cases these dysfunctions build up over years of overuse & abuse.

Blame for injury or pain is usually given to one monumental event, when in reality poor commitment  (coupled with poor technique & instruction during physical training) to the longevity of your body over time has led to many dysfunctions.

Primal Movement Solutions can HELP!
In regards rehabilitation I have over ten years of experience culminating from the exposure to many hundreds of individuals (from a highly athletic & military background) suffering from Acute & Chronic Injuries to the legs, spine, shoulders and arms.

OUR MISSION is to restore your natural movement patterns through the application of Sports Massage, a variety of advanced Soft Tissue Therapy Techniques & Exercise Rehabilitation in order to make permanent change, encouraging long-term reduction in symptoms & a significant increase in your function & performance

We have worked in various sports including:

• Football 
• Running
• Cross-Fit
• Swimming
• Cycling
• Powerlifting
• Ultrafit
• Recreational trainers
• Office bound workers

We only want to fix & treat the most committed individuals, If you want inconsistent & short term results or cannot commit to our vision then Inexperienced Masseurs/ Personal trainers are for you----but just like buying a car, ''If you buy cheap, you buy twice'. 

Example
I recently met a client who had suffered Left neck pain/Right lower back pain for 12 years, during this time he had paid an average of £70-80 an hour for a mixture of seven physiotherapists, Osteopaths and Chiropractors. Each 'professional' gave him a terrible diagnosis ranging from scoliosis, leg length issue to displaced ribs. Unbelievably the Registered Osteopath who made £240 (3 sessions) out of him never actually measured his leg length?

What did we do differently
Following a chat about his issues, a functional movement screening & postural assessment, I conducted a treatment focused on relieving his immediate dysfunction & concerns.
Post treatment there were significant increases in range of movement in the neck & lower back.
He was shown how to stretch muscles correctly (for the first time in 12 years) given correct neck mobility exercises of the cervical spine & we discussed what change he could apply to his daily routine to reduce his symptoms. The most simple being to sleep on his right side to prevent adaptive shortening to the left which was exacerbating his symptoms (again no one had asked him how he slept in 12 years? makes me wonder!!!!) 
Results- Soft tissue therapy in combination with a rehabilitative approach added so much more value to the treatment. How many therapists or professionals really know the functional role of muscles & joints within particular movements in sports? If you don't know simple things like origin & insertions of muscles how can you fully understand its role in movement & how to cause an affect to it?
Since the appointment I have not seen the client again, he is applying his rehabilitative program well & is pain free, is that a negative thing for me a a business....Yes, but to me its more than a job
 

Invest in Primal Movement Solutions for long term results......just check out our reviews (on Facebook), commitment to clients but more importantly our results.

Accreditation: 

• Sports Massage Association Accredited
• BTEC Level 5 Diploma in Clinical/ Remedial Massage

• Registered Exercise of Professionals 
• Exercise Rehabilitation Specialist with 10 years experience in sporting injuries
• Lower back pain specialist
• Pre & Post Natal Exercise Prescription

• Event Work  
• Rocktape & Kinesiotaping practitioner
• NUCO First Aid Qualified
• Football Association (Intermediate First Aid for Sport)

• Charity Events
• Keen to support, contact via Facebook or Twitter

What is Core Stability? Reduce Lower Back Pain & Injuries in Running

There are many opinions on this subject, put simply it can be described as the activation of deep intrinsic muscles that attach directly to the spine providing it with immediate stability in turn preventing unwanted movement of the vertebrae. 

Known as 'local' muscles due to their proximity to the spine 'the core stability' muscles are switched on continuously without any conscious thought and are postural in nature (work for long periods without fatigue). They provide an effective foundation for the larger more superficial muscles (also known as 'global') muscles to produce an effective force & to pull from when you move. 

Imagine having a house with no foundations or a tent with no guide ropes, eventually (not immediately) it will crumble then fail, this is the inevitable outcome of being unable to recruit your core. The superficial 'global' mobilising muscles including the hamstrings, hip flexors, lats and glutes are easy to see which is why people tend to focus on over exercising them.

It is the lesser known muscles we ignore, the two main core stabilizers listed below

Transverse Abdominus (TVA) 
Located at the front of the body, surrounds the trunk like clingfilm pulling the thoroco-lumbar & dorsal fascia taut like a sail to increase pressure & stability around the trunk

Multifidi 
A pair of muscles which scale the entire spine helping to keep it nice & tall, preventing rounding of the back & helping to resist the lure of gravity. These Muscles are like two inner tubes running vertically up the spine, upon contraction they inflate reducing any remaining slack with the TVA 'corset'

FACT
TVA & Multifidus are recruited unconsciously within healthy subjects prior to the movement of the upper or lower limbs, in most cases 130 Milli seconds before you even think about producing movement. In contrast 67% of Back pain sufferers are unable to unconsciously pre-activate the TVA and Multifidi in turn exposing their spines to huge rotational excessive forces and placing an extra 47% more load through the 5th Lumbar vertebrae

Poor Activation
If we are unable to activate these core muscles then we use the larger global muscles to not only move our bodies, but also stabilize the spine.
The big muscles tire out through accumulation of lactic acid/waste build up causing constant pain cycles (generally towards the latter part of the day as they fatigue).
You will start to suffer injuries to muscle tissue and joints including lower back, hip and knees.

The core muscles are arguably the most important yet because we cannot see them it is difficult to understand what must be done to recruit them effectively.

If you suffer from any chronic long term issues such as hip, knee, ankle or lower back pain this is an area you need to improve in- you would have to focus in the short term on developing mobility through the spine, flexibility & fascial release in combination with core activation drills using specialized equipment such as a Pressure Biofeedback Unit.

I get frustrated as a clinician when I see post-natal patients or back pain sufferers conducting advanced movements like planks and sit ups far to soon (some poor boot camps), leading to recruitment of the wrong muscles causing eventual injury.

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