Runner's Knee – What is it, why me and how do I make it go away?

Runner's Knee, also known as ITB Friction Syndrome (or ITBFS for short) is one of the most common conditions a Sports Medicine Doctor will see, particularly during the Spring/Summer months as people become more active and ramp up their training for events such as triathlons or obstacle course races.

What is runner's knee, why does it happen and more importantly what can we do about it?

In my first year as a junior doctor I was a keen 5-10km runner, running 3-4 times per week around central London. I then managed to gain a place in the London Marathon and so I slowly began to build up my training.

I thought I was doing everything right; following a programme to the letter, buying my trainers from a running shop (with a gait assessment) and everything felt good during each training session. That was until injury struck with just 3 weeks to go after running around the beautiful Somerset countryside.

Unfortunately, the knee pain was so intense that I was unable to run the marathon that year – even walking was a struggle, so 26.2 miles was never going to be an option.

I spoke to my GP who referred me to a physiotherapist, and it was at that point that I was diagnosed for the first time with ITBFS.

After four months of physiotherapy, having worked hard on my strength, control and flexibility, I was pain free and back running 10-12 miles at a time with no symptoms. I was ready to restart my training for my deferred marathon place, but this time I was going to take things slower.

Everything felt great until 3 weeks to go (again) when the pain returned with a vengeance. My ITBFS was back.

Why me? How can I make it go away? These were the questions I needed to answer at this point.

Many years later, a sports and exercise medicine diploma and a masters looking at ITB, I might not have all the answers, but I now know where I went wrong.

What is the ITB?

The ITB is a piece of fibrous connective tissue, which is an extension of the Tensa Fascia Lata (TFL) located at the top of your hip.

The band tracts down the outside of the thigh and inserts on a bony bump known as Gerdy’s Tubercle (on the outside of the knee), along with the patella and the femur.

How does the band cause pain?

This is open to some debate. It is generally thought that that band flicks over the lateral femoral condyle as the knee bends and straightens as you run, cycle or walk.

This then leads to inflammation at the area of friction and the patient experiences pain on the outside of their knee.

What factors can trigger ITBFS?

Generally, there are usually 2 or more factors that lead to someone developing ITBFS. These can include:

  • Over-pronation (rolling in of the foot) leading to the knee losing control as it bends. This increases the tension on the band. This could be due to the wrong type of trainers, or because the trainers are reaching the end of their life.

  • Incorrect bike set up resulting in the cyclist having suboptimal positioning on the bike. This affects both the knee position, the tension on the band and the number of times the knee hits the angle of most friction.

  • Hill training – this requires a higher level of strength control required to cope with the increased fatigue that results. Running downhill also increases the number of times the band flicks across the friction point

  • Running regularly on a camber – this affects the position of the knee as the heel strikes the ground which in turn leads to a higher tension on the band and an increased prominence of the lateral femoral condyle

  • Training beyond your body’s current physical capabilities – increasing training should be matched by an appropriate strength and conditioning program to reduce the fatigue effects that occur as the mileage or intensity is increased.

  • Poor flexibility

  • Changes in training program

How is it diagnosed?

This is usually done relatively easily based on the symptoms someone has and what is found during the examination.

An ultrasound scan may be performed to demonstrate if the band is thickened or is there is any fluid surrounding it.

An MRI is commonly performed if the diagnosis is in doubt, or if there is a failure to respond to standard treatments.

How is it treated?

The vast majority of patients improve after a period of rehabilitation.  It is however important to identify the key factors that lead to ITBFS developing in the first place so that these can be addressed and hopefully prevent it reoccurring.

For some people, additional interventions maybe required.

  • A short period of anti-inflammatory medications (very common)

  • Ultrasound guided steroid injection into the point of pain (common)

  • A review by podiatry to perform a gait assessment and to consider orthotics to help with foot positioning (moderately common)

  • Steroid injections into the TFL (rare)

  • Surgical lengthening on the ITB (very rare)

So, what went wrong with me, why did my pain return? As with all ITB related pain, my symptoms came as a result of a number of factors. I had the right trainers; the right training program and I had been through physio but that wasn’t the whole picture.

I made 2 key “errors” that lead to the perfect storm as I increased my mileage.

  • For 4 months I worked hard on my strength and control with the physio. However, I made the schoolboy error of stopping the exercises given when I was discharged, I felt better. All the hard work was wasted as I slowly deconditioned and returned to my old habits. Elite athletes spend almost as much time in the gym as they do in their chosen sport, making them faster and stronger but also importantly to reduce their injury risk.

  • On both occasions I made 1 key change to my training late on. Being based in London the vast majority of my runs were on the flat, but the final runs were on the hills of Somerset – something my body was not conditioned to cope with over a 18-20-mile distance.

I eventually completed the marathon that year with the help of a steroid injection to try and calm my symptoms. I wasn’t pain free, but I finished, and I now know what it feels like to struggle with an overuse injury while trying to achieve a goal. I also know the importance of getting to the route cause of why an injury occurs.

5 top marathon training tips from a Sports Medicine Consultant

  1. Don't make major changes during training, e.g. don't start hill training with 3 weeks to go, don't run in trainers you haven't worn before.
  2. Don't just run - strength and conditioning is an important adjunct that reduces your injury risk.
  3. Persistent pain is not gain! Do not ignore symptoms, the longer you leave them the harder they are to sort out.
  4. If you are struggling and a big day is approaching, consider a steroid injection. This won't fix the underlying issue but might get you through the vent.
  5. Get an up to date running assessment and the right pair of trainers for you.

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