Sunday, 27 July 2014

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

  • 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. 

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