How to prevent runner’s knee (iliotibial band syndrome)

What is runner’s knee?

Runners knee painRunner’s knee is a common niggle that can escalate into a full-blown fun-spoiler if it’s ignored. The cyclists among us might be familiar with the same issue, but under a different name – ‘cyclist’s knee’. It can be a frustrating obstacle for people who are trying to get into a new running or cycling routine, or who are increasing their mileage or terrain difficulty. So what is runner’s knee?

The condition is experienced as pain on the outside edge of the knee, which may also become a little red or swollen. The pain is generally worst at the point when your foot strikes the ground. One possible pattern is to feel the pain at the beginning of a run (although not necessarily), which might then ease off as you warm up, before worsening again until the pain becomes so great that you have to give up and head home. You may also feel pain when you turn a corner. The good news is that with a little understanding of what’s causing this condition, you should be able to make a few changes to get you back to pain-free running.

The first surprise is that runner’s knee is not really a knee joint condition at all. Although the pain is felt at the knee, the problem often originates up near your hip. Let’s look at some simple anatomy…

Tensor fascia lata (TFL), gluteus maximus & iliotibial band (IT band)The key to understanding runner’s knee is the iliotibial band, commonly called the IT band. As the name suggests, this long narrow band runs from near the ilium (the bony bit on the sides of your waist) down to the tibia (just below your knee). It’s pretty-much like an enlarged tendon, meaning that it connects muscle to bone.

If you poke a finger into the soft part just below the ilium bone at the side of your waist, you’ll feel a muscle called tensor fascia lata. This short muscle attaches to your ilium and runs just about a hand’s-width down the side of your leg. Here it blends into the IT band, which then continues all the way down to the tibia (just below the knee). As you’ll see in the diagram, the other muscle that feeds into the IT band is gluteus maximus – your big bottom muscle. When tensor fascia lata and gluteus maximus contract they pull on the IT band and create tension that stabilizes the knee and the hip. Love it or hate (and it seems that many people hate it), if it weren’t for the IT band we would spend a lot of time falling over.

How do I find my IT band?

How to find my IT band

If you sit in a chair or on the floor with your knee bent at a right-angle and run your fingers down the side of your thigh, you’ll feel a bony lump sticking out just at the knee. This is called the lateral condyle of the femur (ie the ‘side bump on the thigh bone’). Now, with your fingers firmly pressing on this bump, slowly straighten your knee. Just as your leg becomes fully straight you should feel your fingers falling off the bump. The bump seems to disappear and your fingers are pushed up towards the knee cap.

What’s happened is that the IT band has moved forwards over the bump and pushed your fingers off it. Now, slowly bend your knee again and you’ll feel the rebump appear as the IT band passes back over it. It can be tricky to feel, but particularly if it’s tight you might be able to follow it up the outside edge of your thigh until it meets the muscles at your hip.

So what causes the pain in runner’s knee?

IT band friction (IT band syndrome or runner's knee)Time for some maths, but don’t worry – I’ll do it for you :-p    Imagine you go for a run for half an hour. With every single stride, your IT band will rub over your lateral femoral condyle and back again. That’s two rubs. Long-distance runners will typically take about 200 strides a minute, so that’s 400 IT band rubs. Multiplied that up to a half-hour run, and your IT band is rubbing over the bone a staggering 12,000 times. Aya beastie!

So it could be that you need to reduce the intensity of your training while your IT band gets used to the friction, but there are a number of other things that you can check before you resort to this.

Muscle condition and massage

Runners knee (IT band syndrome) and massageIf the muscles of your leg were all in tip-top condition it’s likely that your body would be able to cope with all this rubbing – after all, there’s a soft fluid-filled sack (called a bursa) that lies between the IT band and the bone beneath it. If, however, the muscles that pull your IT band become too tight then the IT band will be rubbing more firmly across the lateral condyle. This increases the friction and causes more irritation to the IT band and the bursa. Keeping the muscles tensor fascia lata and gluteus maximus in good condition is therefore really important.

If you’ve shown any of the signs of runner’s knee, be sure to stretch your TFL each day (better to stretch each day, regardless of the time of day, rather than a few times a week just before your run). You may have your own way to do this, but one good way is described here  (please ignore that fact that the guy in the video says you’re stretching the actual IT band: recent studies have found that the IT band is completely unstretchable. What you CAN work on, however, are the muscles that tension the IT band, ie tensor fascia lata and gluteus maximus.)

Many people report good results from foam rollers, but you will save yourself a lot of time and pain if you focus your rolling on the muscles described above rather than on the IT band itself.

Can sports massage help runner’s knee? Of course! Massage is another great way to keep the muscles that we’re talking about in good condition, either as a one-off treatment to knock the problem on the head before starting a new stretching regime, or as part of your body’s regular ‘massage MOT’. An Advanced Remedial and Sports Massage Therapist will be able to identify the tight muscles and check for other possible causes of the pain (eg ligament or cartilage damage). They will also be able to carry out a treatment that includes soft tissue massage and techniques to encourage the brain to ‘let go’ of the tight muscles fibres.

Running on a camber?

Road camberAnother common cause of runner’s knee is running on a cambered surface, ie a surface that is always sloping off to the same side. This is particularly likely to be a problem if you regularly run the same route on a cambered road or pavement. For safety, it’s good to run facing oncoming traffic, but if you’re running with your left foot uphill of your right foot, your foot, ankle knee and hip mechanics will all alter in order to keep your body level. One of the main knock-on effects is a loss of shock absporption in the uphill foot. This and other changes increase the friction of the IT band over the lateral condyle.

Running on a camber will also cause the uphill foot to over-pronate (ie  to roll inwards, down the slope of the camber), which can result in lower back pain (see post) and other conditions that I’ll no doubt come on to in future posts (eg plantar fasciitis, shin splints and medial knee pain). To avoid all of these annoyances try to change your running route a little to steer clear of cambered surfaces.

Knee position while running

Bow-legged running can also lead to runner’s knee, since the IT band has a longer distance to cover around the outside edge of the bowed knee. You can check on your own running stance by looking down at your knees while you run. Are your knees drifting off to the side a little (naughty), or are you keeping them in alignment with your feet?

VMO, vastus medialis obliquusBow-legged running or cycling can be caused by an imbalance in the way you use your thigh muscles, particularly the quad muscles vastus medialis and vastus laterallis. It’s common for the medial (inside) muscle (vastus medialis) to get lazy and allow the knee to drift outwards. Make sure that when you run (or cycle) your knees are staying in line with your feet. Simply being conscious of this for a few runs may be enough to sort out this imbalance and reduce the tension of the IT band. You can also do exercises (eg dips, keeping your knee nicely aligned over your foot) to strengthen the lazy muscle and retrain your brain to keep your knee in the correct plane.

So, in summary, if you’ve been feeling disheartened by your body’s reluctance to get into a new running routine, or to step-up the intensity of your training, it may be that all you need to do is follow a few of these suggestions. Loosen off the musles that tighten your IT band, change your running route to avoid cambered roads, and make sure your knee stays in the same plane as your foot. Now, get out there and enjoy a summer of pain-free running!

Matthew Priest
The Edinburgh Massage

5 Comments on How to prevent runner’s knee (iliotibial band syndrome)

  1. Cheers Helen! You’ll love the course 🙂

  2. Interesting article. I had a running friend ask me about this and I’m just mid-way through my Remedial & Sports Massage training so this has been really useful in educating us both, thanks.

  3. Excellent, Tom! Good luck with it 🙂

  4. found this really helpful! ive been struggling for a while with it and currently training for my first 70.3 triathlon! thanks!


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