Knee Pain and Injuries

In preparation for our Run Beyond Borders marathon, Cooper and I have decided to take on an intermediate marathon training program. Although this is our first marathon and we are essentially beginners, Cooper found that most beginner programs had decreased her normal daily running mileage significantly. For me, a beginner plan was just fine, but with a stable fitness foundation, I figured I can jump on the same program as her.

As training started and progressed, I was establishing my running base quite efficiently and what used to be dreaded longer runs, became more satisfying. I was transforming my physique from an explosive footballer to a leaner aerobic runner. But I soon ran into a huge problem. On a what was supposed to be a 20 mile run, I stopped short at the 14 mile mark due to a sharp pain in my knee. Turned out my symptoms reflected a very common injury: IT Band Syndrome.

IT Band Syndrome sounds very technical and chronic as the name implies, but after uncovering facts about my injury, it all makes sense. Below is an excerpt from Knee Pain a 3 part posting by Ray Webster about the anatomy of the knee and some common causes for knee pain. This gave me good insight on what happened to my knee. Here’s a recap of my lessons learned.

1. Warm up properly and thoroughly. We all know what a proper warm should be, but we often save some warm up time within our actual workout to “warm-up-as-we-go”. Having the discipline to fully increase body temperature, stretch and actually break a sweat during a proper warm up, will despite taking longer to jump into your workout, save you time in comparison to the time you spend during rehabilitation of an injury.
2. Strengthen muscles and core. Because I found myself sitting at a desk job, I did not realize how weak my butt was getting, literally. The decrease in strength in my Gluteus muscles from sitting long periods of time, played the biggest role in my injury. This takes understanding you body well and maintaining strength throughout your large muscles groups, your supporting muscles and the core in able to prevent injury.
3. Increase work load progressively. My problem was that I knew I was pretty fit and I assumed adding more miles to my workouts and my already established fitness routine wouldn’t be an issue. But I am not a runner, I am a footballer, who has been used to short explosive movements in different directions, not necessarily continuous and repetitive slow twitch movements for extended periods of time.  Although my fitness level might be high, my body and my muscles needed to be trained for extremely different roles and they need to be able to handle long periods of repetitive motions for something like a marathon or long distance running.

So, the concoction for the perfect beginner injury for me was the combination of a weak tush from sitting at a desk, mixed with the confidence of increasing mileage and smashed with a lazy warm-up. I hope gives some insight on things to be conscious of when taking one something as simple as “running”.

At the very moment we have 34 days until our Run Beyond Borders and my training has been derailed a bit, but proper aggressive rehab is keeping my aerobic fitness stable.

Knee Pain Part 2: Lateral Knee Pain

The Running PT Ray Webster
IT band syndrome and IT band friction syndrome are two common diagnoses that mean the same thing for lateral knee pain.  I know first hand how painful and annoying this type of knee pain can be.  Years ago, I was on a run two days before a big race when I started feeling a slight pain along the outside of my left knee.  I figured it would go away.  But within five minutes it had progressed to a very sharp pain, like a knife was being jabbed into the outside of my knee every time my foot hit the ground.  I had to stop and walk home.  Over the next two days, my knee felt tight & sore and stairs remained painful to walk down.  After a few days of rest I tried running again but the pain returned, this time more quickly.  A trip to the knee doc and an MRI only intensified my frustration.  He said there was nothing showing up in the MRI.  And his advice – my blood pressure still goes up even thinking about this –  ”I don’t see anything wrong with your knee.  Maybe you just shouldn’t run so much.  Do you like biking?”  WHAT!!!!!?????  Are you kidding me!?  I couldn’t believe THAT was his answer.  Fortunately, I was half way through the Physical Therapy program and eventually figured out that I had IT band syndrome.  So I’m always very excited when I can prevent other people from having that same frustrating experience.

Like I said in part 1, there are always exceptions to types of knee pain.  Not everyone will have the exact same intensity of pain that I had.  Also, there are other causes of lateral knee pain (see disclaimer below).  But for runners who haven’t fallen or had some other traumatic knee injury, IT band syndrome is usually the problem.  Below is an explanation, beginning with a self-assessment to help you better understand what’s going on.

Start by standing in front of a mirror with shorts on so you can see our knees.  Stand relaxed and look at your kneecaps.  Do you see one or both oriented somewhat inward instead of straight ahead?  In an extreme case, a person might even notice their knees are closer together than their feet. Next, you’re going to tighten your glutes, AKA: squeeze your butt muscles (not with your hands, I actually had a guy do that once) – watch what your knees do – they’ll slightly rotate laterally to the point where your knee caps are now facing more forward.  Tighten and relax your glutes a few times and you’ll see your knees rotating in and out.  As you’re tightening your glutes you’re externally rotating your hip, which directly affects your knee orientation.  If your knees face inward when you stand relaxed, then the hip external rotator muscles that should be maintaining the alignment of your hips have become weakened.  This leads to knee pain.  So when you need your muscles to support your hips in the proper position while running (which is much more demanding than standing), they eventually fatigue to the point where they can no longer do their job.  This is why your knee pain doesn’t set in until you’ve run a few miles.  Over time, the distance you could run would lessen, stairs would become more painful and eventually you’d have knee pain all the time.

What’s causing my knee pain if the problem is in my hip?  The IT band starts at the hip as a wide tendon where it attaches to the hip bone (Ilium), the glutes and a small muscle called the tensor facia lata (TFL).  It runs down the outside of your thigh to just below the knee, attaching to the tibia.  This is why it’s called the “IT band.”  It connects the ilium to the tibia.  As the IT band approaches the knee, it rubs against the lateral condyle of the femur (see small image).  I like to use the car front-end alignment analogy to explain this:  If the alignment is off in a car, the tires wear more quickly.  The problem is not the tires, it’s the parts that align the tires.  In our knees, the IT band pain is the same as the worn tires, just a symptom of the root problem.

How is this related to running?  Think of your knees as simple hinge joints, similar to a door hinge.  They can only go forward and back.  Our kneecaps point in the direction that the hinge is facing.  So if you’re running forward you want your knees to flex straight forward and back, not at an angle.  If your knee is rotated inward, the friction of the IT band on the lateral condyle is greater and things become irritated, especially during repetitive movements like running.  When you see runner’s with their feet kicking out to the sides when they push off, you’re seeing the poor biomechanics of hip internal rotation in action.  They probably have painful knees.

How did this muscle weakness happen?  The short answer is sitting.  When we sit for hours at a time, the muscles are not active.  The use-it-or-lose-it philosophy rings very true here.  Over time, the muscles become more accustomed to being at rest and lose their strength.  I’ve noticed a trend when I talk to people about this subject.  The knee pain usually starts after about 5-6 years of working at a desk job.  Unfortunately, you can count graduate school as a sit-down job.  Incidentally, sit-stand work stations are becoming more popular and I strongly encourage people to consider those if they’re stuck behind a desk work.

How do I fix it?  The permanent fix is to re-strengthen the hip external rotators.   In the mean time, there are a couple of things to try that might give some temporary relief.

You can never go wrong with putting ice on the painful area.  This will help decrease any swelling and pain.

Many people try using a foam roller on their IT bands.  That works, but it can be quite uncomfortable and not everyone has positive results.  In the clinic, I do a manual technique called the IT band release.  The closest thing I can describe that a person can do on their own legs is to work up and down the outside of your leg (4-5 times) pressing down and twisting, similar to how you’d open a medication bottle.  You do this WITHOUT any massage cream or lotion.  The idea is to get the layers of fascia, muscle and connective tissue to move independently of each other under the skin. It will feel like a dull ache as you apply pressure.  You can have another person do this for you as you lay on your side, just be careful because your leg will be very sensitive the first few times.  If done correctly, when you stand up and walk around after, your knees should feel lighter and easier to move.  This usually carries over to running.