Overtime, with increased mileage, less than optimal mechanics, and inadequate recovery there is often tissue failure resulting in an injury. “Runner’s knee” is not one condition. Runner’s, let’s chat about your knee pain…”
ITBFS and PFPS in the Runner
Training errors are believed to be one of the most common causes of overuse injuries. Overtime, with increased mileage, less than optimal mechanics, and inadequate recovery there is often tissue failure resulting in an overuse injury. “Runner’s knee” is not just one condition. Let’s chat about the similarities and differences between iliotibial band friction syndrome, and patellofemoral pain syndrome; two very common overuse injuries we treat in the recreational, competitive and elite runners.
ITBFS: Iliotibial Band Friction Syndrome
Often athletes complain of poorly localized pain on the outer aspect of the knee, related to repetitive friction of the iliotibial band sliding over a bony prominence on the femur. Symptoms are usually aggravated by running long distances, excessive striding, and will be more severe running downhill. Contributing factors include muscular imbalances of the tissues surrounding the hip and knee as tightness,weakness and poor motor control. Common clinical patterns we see include core/abdominal and hip weakness, trunk and hip compensations, knee valgus (collapsing inwards) with single limb activities. For all of my superstar tri-athletes, please note that iliotibial band syndrome is also prominent in cyclists. Although each cycle stroke is less irritating than running, sheer repetition in the “friction zone” of slight knee flexion can certainly make up for it.
PFPS: Patellofemoral Pain Syndrome
Also a common overuse injury which is usually poorly localized pain in the front of the knee and around the patella (kneecap). Often athletes complain of pain during and after physical activity, walking up/down stairs, squatting, and while sitting with the knees bent. Contributing factors include malalignment of the lower extremity and/or the patella (“mal-tracking”); muscle tightness and muscular weakness (imbalance); and overactivity. Common clinical patterns we see are weakness in eccentric strength of the quadriceps muscle, tightness throughout the lateral thigh and iliotibial band, and weakness in the hip abductors and extensors.
I educate my patients using the train on track analogy. The train is in reference to the patella, and the track is in reference to the femur (thigh) and tibia (shin). As the train must move along the track, “mal-tracking” of the knee cap will therefore occur with weakness in the hips and/or poor ankle strategies. With faulty running mechanics, as the thigh bone moves towards mid-line (adducts) and/or internally rotates it forces the knee cap too far outside it’s happy place which increases the amount of stress along borders of the patella. If you want to change the position of the patella, you have to change the track.
Hips don’t lie!
Many strength training programs for runners will focus on hip abductor and extensor training in order to optimize lower body alignment. A pelvic drop, femoral adduction and internal rotation are all poor mechanics and can result in injury overtime. Don’t forget about your feet! Researchers find a higher incidence of ITBFS and other lower extremity injuries in athletes who over-pronate. Over pronation can be corrected by internal and external factors. Proper footwear is a common external factor impacting your ankle /foot mechanics. Experts recommend 300 – 500 miles / per running shoe depending on past injuries, training terrain, and mileage. All of our runners are educated on ankle / foot mechanics and given exercises to stretch tight tissue and strengthen muscles that support the arch of our foot.
Injury Prevention (both!)
Many risk factors are avoidable with an individualized, and balanced training program. In relation to ITBFS, decreased hip abductor (outer hip) strength leads to pelvic drop or increased hip adduction as your body translates over a fixed foot. Overtime, this repetitive hip adduction moment places detrimental stress on the Iliotibial Band. In relation to PFPS, decreased hip abductor and extensor strength can results in excessive hip internal rotation with movement. Overtime, this repetitive hip internal rotation places stress on aspects of the knee cap that are not designed for repetitive impact. This is inadequate frontal plane stabilization, and can be addressed with neuromuscular re education and exercise to strengthen hip abductors / extensors, core / abdominals. As mentioned above, eccentric quadriceps strengthening is also important for knee stability as your leg accepts your body weight with each and every stride
The key to any training program is balance between strength, stability, flexibility and tissue mobility. Sport – specific, individualized training programs are important to maximize your ability to actively and effectively absorb impact forces and prevent injury over increased mileage. Shock absorption techniques are done either actively by muscles and / or passively by bone/ ligament/ cartilage. When muscles fatigue and do not meet the demands of activity, passive structures take the heat.
We recommend that our runners participate in cross-training programs throughout the year. Cross-training is incorporating another kind of fitness workout to our routine; such as strength training, cycling, swimming, pilates to supplement running. The variety of demands builds strength and mobility in muscles that running doesn’t utilize. Overall aiming to prevent injury by correcting muscular imbalances. And the variety prevents boredom and burnout.
Also, try to change up your “tempo” to better match demands of running. Training for endurance means less weight, but more repetitions. Try 3 sets of 12 to 15 repetitions at a 2-1-3 (concentric-isometric-eccentric-isometric) tempo with 60 seconds of rest between sets.
Rehabilitation: In the acute phase, treatment includes activity modification, motor control “mat exercises”, gentle stretching and soft tissue therapy for any myofascial restrictions. Once symptoms have been consistently managed, the recovery phase focuses on integrating “mat exercises” to functional demands in order to optimize kinetic chain alignment and running form.
There are now so many fun self massage, mobility and recovery tools found online. Self management strategies to facilitate recovery include myofascial release techniques. “Myo” refers to your muscles, while “Fascia” is targeting the connective tissue which plays an important supportive role to the musculo-skeletal system. Foam rolling is one way we are able to address adhesions within the fascia, or “knots” in the muscle fibers allowing our muscle to function maximally. Foam rolling is one common self management tool used for improving warm-up -blood flow, myofascial release; as well as improving recovery after endurance and strength efforts to reduce muscle tension and soreness (DOMS).
Part II will provide you all with a comprehensive manual with pictures/ videos to optimize your recovery days! Need someone to hold you accountable?? Runners, check out our new group training class specific to the Endurance Athlete! Each class will be sixty minutes of cross training to maximize strength, stability and flexibility / recovery.
The FIT Institute is a physical therapy and sports performance facility in North Center. We increase the of an athlete’s career by teaching proper movement patterns that often lead to overuse injuries, we do this by bridging the gap between physical therapy and sports performance.