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  • Writer's pictureMurray Kovesy

Why I Get Knee Pain with Running - Iliotibial Band Syndrome

Updated: Jan 9, 2020

Iliotibial Band Syndrome (ITBS) or Runners Knee is an overuse inflammatory condition most commonly seen in runners causing lateral (outside) knee pain. ITBS is a repetitive strain injury common with athletes increasing their training program, in particular long distance runners training for a marathon. ITB syndrome accounts for 22.2% of all lower extremity injuries in runners (Clinical Journal of Sport Medicine). Usually ITBS recovers quite easily with rest in conjunction with ice, physical therapy, foam rolling and stretches. Unfortunately it is a condition that has a nasty tendency to become a chronic problem and extremely frustrating for runners.

The ITB is a thick band of fascia (connective tissue) crossing both the hip and knee joints extending from the pelvis to the knee. The movement of the ITB during flexion and extension of the knee and hip causes friction and inflammation leading to ongoing knee pain with running, cycling and even weight lifting exercise. In Latin iliotibial translates from ‘ilio’ meaning iliac crest of the pelvis or hip and ‘tibial’ meaning tibia or shin bone. ITBS occurs due to tightness of the hip muscles chiefly a muscle called tensor fascia latae (TFL) and gluteus maximus. When we break it down from Latin, the word ‘tensor’ means to tense, ‘fascia’ is the Latin term for ‘band’ and latae means “side”. TFL roughly translates to ‘the muscle that tenses the band on the side’.

How do you know when you have ITBS? Having had ITB issues myself I’ve experienced firsthand how frustrating and nasty the condition can be. Halfway through my 15km run my left knee started giving me sharp pain with every step and gradually becoming unbearable to the point I had stop and walk. Two days after going up and down the stairs of a three storey home was a challenge to say the least. Knowing what the condition was gave me some confidence it was nothing too serious but didn’t help with the pain. I knew it was due to the fact I pushed the distance and pace too much too soon without adequate rest. In most cases ITBS is caused by errors in training load rather than solely the body’s fault.

Many runners mistakenly believe they have a serious knee injury as the symptoms of ITBS mimic conditions like a meniscus tear, lateral ligament damage or patellofemoral pain syndrome. Pain of the lateral knee when the foot strikes the ground is the main complaint amongst athletes. The pain typically begins within the first 10 minutes of the run and will worsen as the run continues. In particular pain can be aggravated by downhill slopes or stairs. Pain can be sharp and often debilitating making it difficult to continue running. The knee may ache above the joint line and radiate downwards post exercise. Snapping of the ITB can sometimes occur over the lateral knee at 30-40° of knee flexion with exercise.

Patellofemoral pain syndrome (PFPS) is another repetitive strain injury which can cause similar symptoms in runners. The easiest way to tell the difference between the two conditions is simply by the location of the symptoms. PFPS affects the kneecap and surrounding area, whereas ITBS characteristically affects primarily the outside of the knee. A meniscus tear and lateral ligament damage is often due to a specific traumatic injury seen in high contact sports and rapid changes in direction unlike ITBS which is non-traumatic in nature.

Iliotibial Band Syndrome is said to be more common in women because of their anatomically broader pelvis thus causing knee pressure and strain on the ITB. Many people become over dominate in the quads due to over exercise and biomechanical factors. Weakness of the hip abductors, mainly the gluteus medius, can result in a lateral pelvic tilt and excessive strain of the ITB. Fredericson et al evaluated twenty four runners with ITBS and found that all runners in the study had weakness of their hip abductors in the affected limb when compared to their unaffected limb and controls. Understanding the importance of symmetry in the body is helpful in preventing ITBS. When activities alter symmetry of the pelvis and hips symptoms often occur. Other aggravating factors include running with worn out shoes, running on a sloped banked surface, running on concrete surface, over-pronation of foot, one leg longer than the other, over training without adequate warm up and cool down and anatomical thickness of the ITB.

Treatment is focused initially reducing the pain and inflammation with ice and rest. Rest is the most valuable thing here but often ignored especially with determined runners that will try and run through the pain. A reduction in running intensity and distance is needed and also avoiding doing squats or lunges. Use a cross-trainer, elliptical machine, swimming, pool running, cycling and rowing to allow for recovery and symptoms to settle whilst training. A physical therapist needs to assess and treat your ITBS as early as possible. To prevent occurrence long term a postural and gait analysis assists in correcting abnormal biomechanics.

Myotherapy, remedial massage and Dry Needling treatment involves the release of TFL, glutes, quads, hamstrings and ITB. Dry Needling has also been effective and widely used for the condition. The use of a foam roller over the ITB can be painful initially therefore a spikey ball release of the TFL in the hip is a preferred option. Is it time to throw out and replace those old worn-out runners? Ideally this needs to be every 600 – 700 kms. If problems persist a podiatrist may look at orthotics for over pronation of your feet. Although ITB syndrome is often acute in nature taking 2- 3 weeks to recover it can reoccur and progress to a chronic condition lasting more than 3 months preventing running if not treated appropriately.

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