By Sam Carter, M.D. Orthopaedic Specialist Medical Director, Kentucky Derby Festival Marathon and miniMarathon
I am now almost two months into my training schedule for the Kentucky Derby Festival miniMarathon, and I finally feel as if I am making some progress. Over the past two weeks, it hasn’t been as much of a struggle to complete the distances, and I’m finally starting to improve on my pace. The past two Saturday long runs were 9 and 10 miles, and while I was very happy with those runs I definitely felt them in my legs the following Sundays. Thankfully, I haven’t had any more hamstring issues since the incident I wrote about in the last training blog, and I attribute that to paying special attention to my stretching recently.
I have had some nagging discomfort in my left knee for months now on the outside, or lateral, part of the knee. Not enough to interfere with a run, but just enough that I can’t completely forget about it. This is a very common problem that many runners develop called IT band friction syndrome (ITBFS). Since I am aware of it, I have been able to focus on stretches and keep it from hindering my training, but I haven’t been able to eradicate it completely.
What is IT band friction syndrome? First, let’s talk about anatomy. The IT band is a broad, thick tendon that runs down the lateral side of the thigh. It originates from muscles that attach on the front and side of the pelvis, crosses the knee joint, then attaches to the front lateral side of the tibia just below the knee. Since the IT band crosses the knee joint, it glides across the femur at the knee joint as the knee flexes and extends. With repetitive activity, such as running or cycling, it can cause friction at the most prominent portion of the femur at the knee, the femoral epicondyle. This force is highest between 20 and 30 degrees of knee flexion, and if the IT band is excessively tight or your running mechanics cause increased pressure, the bursa and knee synovial lining under the IT band can become very inflamed, causing IT band friction syndrome.
One mechanical factor that can exacerbate IT band friction is pelvic tilt, caused either by a leg length discrepancy or much more commonly, running on a slanted surface. This most often affects runners who like to train on highways, since most roadways are highest in the center and then slope down on both sides. Running on an angle like this causes an artificial leg length difference and a tilted pelvis, which can place increased stress on the IT band at the knee. Other mechanical factors that have been cited are genu varum, or a bow-legged deformity at the knees; internally rotating the foot at foot strike; and weakness of the hip abductor muscles.
IT band friction syndrome generally causes a burning pain on the lateral (outside) part of the knee, just above the knee joint line. The pain is usually worse during activities and subsides at rest except in severe cases. It will commonly get worse as you continue your run and may eventually cause you to stop. You may even feel a rubbing or snapping sensation as you flex and extend your knee in the 20- to 30-degree range of flexion. The pain is generally made worse if you press on the epicondyle (the sore spot just above the knee joint line) as you flex and extend your knee, and you may even feel crepitus – a crackling or popping sensation.
Treatment for IT band friction syndrome is conservative and only rarely leads to any surgical intervention. As with most overuse running injuries, rest and ice are helpful in calming the inflammatory symptoms, and an anti-inflammatory medication can help ease the pain. Stretching is the mainstay of treatment and is generally the focus of most treatment regimens. The IT band is an awkward structure to stretch, and simply explaining the stretches causes more confusion. Check out this link from “Running Times” for good pictures of some IT band stretches and some IT strengthening as well. If the mechanics of your foot-strike are the source of your problems, then a review of your shoe wear may be in order.
In the small percentage of cases that don’t respond to conservative treatments for many months, surgical intervention can help alleviate the problem. A portion of the IT band at the knee can be excised to remove the cause of the friction. The IT band can also be lengthened with specific cuts instead of removing part of it. Again, these procedures are only for extreme cases that have failed all other attempts at treatment.
It’s not long now until the Triple Crown races are upon us. I hope your training is going well. Just remember to listen to your body, as it will tell you when something needs attention. Good luck with the races!