Wednesday, October 26, 2005

The Truth About Lateral Knee Pain

Many athletes complain of the condition known as “Iliotibial Band Syndrome” or ITBS. The condition often presents as lateral knee pain (pain outside the knee), or also as lateral hip pain. This condition is particularly prevalent among athletes involved in running or cutting activities, such as football and hockey athletes, long distance runners, and sprinters.

To date there have been many different approaches to the treatment of ITBS. Some include stretching, massage, ultrasound, and soft-tissue techniques, all with a varying degree of effectiveness. While the treatment will often clear up the patient’s symptoms, there is a large degree of recurrence weeks, months, or years down the road with continued activity.

The most commonly overlooked aspect of the treatment of ITBS is the active strengthening and rehabilitation of the involved structures. Until recently, it was not entirely understood what the precipitating factors were in the development of ITBS. A recent study in the Clinical Journal of Sports Medicine (Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, and Sahrmann S. Hip abductor weakness in distance runners with iliotibial band syndrome. CJSM 2000; Jul 10(3): 169-175.) revealed that runners with iliotibial band syndrome had decreased strength in the muscles that abduct the hip (raise the leg out sideways) when compared to runners without ITBS. These muscles, otherwise known as the gluteus medius and minimus, also play a large role in the stability of the pelvis. Standing on both feet, if you raise your left leg in the air, the right gluteus medius/minimus is responsible for keeping the hip steady so that it doesn't buckle underneath you. You can imagine the implications of a weak or tight gluteus medius when it comes to sporting performance. If these muscles are not working at peak function, then you will see a lot of lateral deviation of the pelvis during activity and power and speed are lost. If the gluteus medius/minimus muscles are weak, nearby muscles attempt to take up the slack. The tensor fascia latae muscle, which acts as a hip flexor and a weak hip abductor, will attempt to accomplish the action of the weakened glutes. Now here is where it gets interesting. The tensor fascia latae (TFL) is directly continous with the iliotibial band (ITB), and any contraction of the TFL transmits itself down the ITB. Because the ITB attaches at the lateral knee at it's most distal end, this is why you get lateral knee pain as a result! In essence, knee pain is a result of weakness at the hip! If you understand the mechanism, then you will also understand why treatments aimed solely at the ITB and lateral knee and only temporarily or not at all effective.

This same study that discovered the relative weakness of the hip abductors in persons with ITBS also revealed that after a 6-week rehabilitation program aimed at strengthening the hip abductors, 22 of 24 runners were pain-free, and were able to return to running and did not suffer any recurrence of their symptoms after 6 months. As you can see, active rehabilitation was the key to resolving the issue.

Soft-tissue techniques such as Active Release Techniques ® and Graston Technique ® are very effective in treating the symptoms of ITBS. Combine these techniques with a hip rehabilitation program, and not only will your pain resolve, but it will be less likely to return. Be careful when discussing a rehabilitation program with your trainer or health care practitioner. The strengthening of the hip abductors demands a very particular pelvic position in order for the glutes to contract in the absence of the TFL. If the TFL is still trying to compensate for a relative weakness, all you are doing is exacerbating the problem instead of fixing it. Make sure to consult a health care practitioner with a strong knowledge of rehabilitation. Don't let a simple problem side-line you from doing what you love.