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02.09.08

Knee pain from running - expert advice

In the third of a new series of features on Sportsister we ask our expert panel to answer your sporting questions. This week Nicki de Leon, a sports injury physiotherapist, looks at knee pain.

If you would like your health, fitness or training questions answered just email us at [email protected].

I have just started increasing my running mileage as I am training for the New York marathon but have been experiencing pain and burning on the outside of my knee towards the end of my longer runs. It is now getting to the point that the pain lasts for a couple of days after a run. This is obviously starting to affect my training. What do you think this could be and what should I do about it?

Iliotibial band friction syndrome (ITBFS) is one of the most common causes of lateral knee pain in runners. The iliotibial band (ITB) is an extension of connective tissue that runs down the outside of the thigh (like a trouser seam). It originates in the tensor fascia lata (TFL) muscle at the side of the hip and finishes at the top end of the outside of the tibia (lower leg bone).

ITBFS is an overuse injury that produces pain on the lateral (outside) knee during running. Pain is generally caused by an unusually tight ITB, the undersurface of which causes friction over the lateral condyle of the femur (thigh bone).

If you run your hand down the outside of your thigh, you will feel a knobbly piece of bone just before you reach your knee. This is usually where the pain from ITBFS is felt. When the knee flexes the initial 30 degrees from extension, the ITB moves from front to back over the condyle. In runners, this occurs near or just after foot strike during the contact phase of the gait cycle. Downhill running reduces the knee flexion angle and can aggravate ITBFS, while sprinting and fast running increase the knee flexion angle and are less likely to cause the syndrome.

Biomechanical and training factors play an important role in the onset of this problem. A sudden increase in running mileage or intensity when you are training whilst fatigued can alter your running biomechanics, making you susceptible to injury.

Continuous training without rest days will also contribute towards this overuse injury as you are not allowing your soft tissue to recover between runs. The role of the TFL/ITB complex is to internally rotate the hip and assist the Gluteus Medius muscle in the abduction of the thigh during the stance phase of gait. It also helps the hip flexors to flex the hip.

Therefore, if the TFL becomes overactive and dominant, it causes the gluteus medius muscle to become inhibited and weak. This can lead to the lower limb being forced into internal rotation (causing the TFL/ITB complex to become even tighter and dominant) and often uncontrolled pronation of the foot. These biomechanical problems can then result in increased friction of the ITB.

How do I prevent this?

- One of the most effective ways to prevent any running related problem, is to have your biomechanics assessed by a physiotherapist or running coach. Any weaknesses that are identified can then be prevented from developing into an injury through a series of stretches and rehabilitation exercises to strengthen the appropriate muscles. Sixphysio are now offering 30% discount off all running assessments at their clinics around London - see details at end of feature.

- Don’t train whilst tired and have rest days in between training days.

- Gradually increase your running mileage, don’t suddenly double the miles. If you are not running during the week, do not expect to suddenly be able to increase your mileage at the weekends.

- An essential strategy to prevent muscle and soft tissue tightness is to stretch daily, concentrating on the hip flexors, quadriceps, TFL/ITB complex and hamstrings.

How to stretch correctly

Hip flexor stretch:

▪ In a kneeling lunge position, tuck your pelvis under
▪ Lean forwards until the stretch is felt in the upper thigh
▪ Hold 30 seconds then repeat on the other side
Hip flexor/quad stretch:
▪ In a kneeling lunge position, tuck your pelvis under and hold your foot, as shown
▪ Draw your foot to your bottom and Lean forwards until the stretch is felt in your thigh
▪ Hold 30 seconds then repeat on the other side

4/Hip and groin stretch:

▪ Lie on your front with abdominals engaged
▪ Bend your right knee, and hook your foot underneath the left leg to open your knee out to the side, aiming to rest the right side of your pelvis onto the floor
▪ Hold for 30-40 seconds and repeat on the other side

ITB/Side stretch:

▪ To stretch the right side: In standing cross your right ankle over your left foot. Reach your right arm up and over to the left side. Shift your hips towards the right to increase the stretch. This should be felt on the outside of your right hip.
▪ Hold for 30 seconds then repeat on the other side


Hamstring stretch:
▪ Lie on your back, in a neutral spine position
▪ Bring one leg to 90 degrees and hold behind the thigh as you slowly straighten your leg to reach the foot to the ceiling. Your knee does not need to be fully straight.
▪ Keep your tailbone on the floor and hold for 30 seconds
▪ Stretch should be felt behind the leg, not in the lower back.

Stability exercises

Stability retraining for the lower limbs is crucial in resolving biomechanical predisposing factors. The idea is to perform single leg squats and lunge type exercises which are then progressed to enable you to incorporate them into your running. Always perform these exercises in front of a mirror to ensure that your alignment is correct and that your knee remains in line with your 2nd/3rd toes. This ensures that the Gluteus Medius activates effectively and that the TFL remains underactive.

Mini knee bend:

▪ Align your body into correct posture and engage the deep abdominals

▪ Bend at your hips and knees to perform a small squat.
▪ Knee caps must track in line with the 2nd/3rd toes, but should not go past them.
▪ Return to the start position by tensing the inner quads and gluteal muscles
▪ Repeat 10-15 times. You can incorporate longer holds to improve endurance.

Single leg squat:

Stand on one leg tightening your gluteals (buttock muscles) and deep abdominals to keep your pelvis level
Slowly squat down a small distance ensuring your knee follows in line with the second toe and your foot does not roll inwards.
Pelvis must stay level.
Return to the start position by pressing through the heel and tensing the inner quad and outer bottom muscles
Repeat 10-15 times

Glutius Medius at wall with squat:

▪ To work the right gluteal, stand side on to a wall on the right leg with the left knee resting on the wall, as shown

▪ Gently contract the buttock muscle on the right leg and press into the wall with the left knee without moving the pelvis or spine

▪ Hold for 3 seconds

▪ Then perform a small knee bend ensuring your knee stays in line with your 2nd/3rd toes

▪ You may feel a burn on your outer bottom muscles. This is the Glut Med muscle working. Repeat 5 - 8 times then rest

▪ Perform 6-8 small knee bends before working the other side and then repeat these sets 2-3 more times

Lunge alignment:

▪ Align the spine in neutral and engage the deep abdominals. Take a big step forwards then lunge down ensuring your pelvis does not twist and the spine stays in neutral.
▪ Allow your back heel to lift and keep the front kneecap line with the 2nd/3rd toes
▪ Return to the start position by pressing through the front heel to activate the inside quadriceps and gluteals.
▪ Repeat 10-15 times on one leg, then change to the other side

Remember : none of these stretches or stability exercises should cause any discomfort. If they do, it means you are either not doing them properly or they are not appropriate for you to do. You are always best to see a qualified Physiotherapist if you are experiencing any pain or problems whilst running or doing any other sport.

Nicki de Leon, Sportsister
The Women’s Sports Magazine

Nicki de Leon is a sports injury physiotherapist with over ten years experience treating elite sportsmen and women and professional dancers. She was the official physio of the British Paralympic swimming team for over three years and attended the Paralympic Games in Athens 2004.

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