Knees

Ilona Barash RunI’m about 11 miles into a 17 mile run, two weeks before the Boston Marathon, when I’m crippled by knee pain. Sharp, stabbing pain to my lateral right knee, like someone was jabbing it with a hot poker. As I screech and limp to a halt, I’m kicking myself as I know exactly what this is and what I have NOT been doing, and therefore why I have this pain. I’ve had it before and take care of it all the time in clinic, but that doesn’t make the pain any easier to bear. I hobble the rest of the way home in pain, walking, frustrated that after all the hard work that went into qualifying for the Boston Marathon, I may not be able to run it due to one of the most common causes of knee pain in runners, one that is entirely preventable and treatable if you give it the time and effort: Iliotibial Band Syndrome (ITBS).

I’m going to go over the two most common causes of overuse knee pain in female athletes during this blog post, and what you can do about them. I’ll try to do a post later in the year about ACL injuries. All of these (including ACL injuries) are more common in women than men, although they certainly occur in both genders. Most of the increase in incidence in women is due to our generally wider hips and generally knock-kneed anatomy, putting extra stress on our knees. The good news for the overuse injuries is that they are not dangerous. You will not be causing permanent damage if you continue running or exercising through them, but you will likely take longer to heal and become pain free. As always, if you have any questions about your diagnosis, I would urge you to go to your doctor for more information and definitive diagnosis – don’t trust anything you read online. A good physical therapist is also wonderful for going over exercises to heal these common injuries.

In general, for overuse injuries, the following basic rules apply:

  1. If you get an overuse injury, you need at least relative rest to allow it to repair. This doesn’t necessarily mean NO activity, but rather no activities that are painful. If you got it running, consider swimming or biking until it heals. If you have a big goal event coming up and you can run through the pain, you are probably OK to do so without causing permanent damage, but you will likely be in pain longer as a result.
  2. A short course of anti-inflammatory medications such as ibuprofen or naprosyn (Advil, Motrin, Aleve) will likely be helpful, along with icing and rest. If you take anti-inflammatories, take them with food (AFTER a particularly hard exercise, not before), stay well hydrated, and pay attention to side effects such as stomach pain which may be an early sign of ulcers or gastritis. When you ice, ice for 20 minutes at a time, ideally three to four times per day.
  3. A combination of a strengthening and stretching program will likely get you back into your former activity level, but once you’ve had one of these problems, you are at risk for getting them again unless you keep up on your stretching and strengthening even when you are not in pain.

Iliotibial Band Syndrome

The “IT” band, we’ve all heard of it, and many of us have had issues with it. When I walk into a clinic room and my patient says they have pain on the outside, or lateral, knee, and that they are a runner, nine times out of ten this will be the cause. The IT band starts high up on your pelvis, near your iliac crest, and extends past your lateral hip all the way down below your knee to a point on your tibia called Gerdy’s tubercle. It functions in a few ways: at the hip, it flexes and abducts (moves your leg away from your center); and at the knee, it provides lateral stabilization and some flexion. It works in synergy with the buttocks muscles, the gluteus medius and minimus, along with some of the other hip and core stabilizing muscles. Runners often have problems with this band getting strained, then rubbing just above the knee joint itself, because it works hard during running for stabilization and yet is often weak and stiff. The key to treatment of IT band syndrome is a combination of stretching the IT band, and strengthening the gluteus medius. Most runners have heard of stretching the IT band, and I would urge you to search online for IT band stretches – there are multiple ways to do this. While some people swear by foam rolling as well, there actually is not scientific evidence that this works, but certainly there is no harm in giving it a try.

What really works the best for this condition is strengthening your lateral hip muscles, the gluteus medius and minimus. I’ve seen multiple fit, experienced, fast runners in clinic who come to me for evaluation, and I can overcome their hip muscles with one finger – you might guess that this weak of a muscle will not be working well against your body weight while running! Doing the lateral hip strengthening exercises three to five days a week will save your IT band, and along with relative rest you should see results in about two to three weeks.

There are also multiple ways of strengthening your hip abductors, but the best ways I’ve found are the following:

  1. Lateral leg lifts. Lie on your good side, and do lateral leg lifts with your bad leg straight. Its easiest to start doing this against a wall, to keep your hips square and prevent them from rocking forward or backwards as you move your leg up, but once you can be stable, move into the center of the room. Start with 20 reps, work up to three sets of 30 reps.
  2. Side planks. Lie on your side, on your elbow with your elbow bent. Keeping your hips square, raise them up so your body is straight, holding in your stomach muscles. Hold for 30 seconds, three reps, work up to holding for 60-90 seconds. Eventually, you want to combine the leg lift with the side plank to get a full hip and core workout.
  3. Loop a theraband into a loop about 12 inches long, and put it around your ankles. Keeping your feet pointing straight ahead, start with your feet about 15-18 inches apart and “crab-walk” sideways, one foot at a time, with constant pressure on the band, for about 20 feet. Do this in both directions, one time with your knees straight and one time bent, making sure that you stay square with your shoulders over your hips, toes facing directly perpendicular to your direction of travel, and a tight core. Feel the burn in your lateral hips!!

Anterior Knee Pain

Also known as Patellofemoral Pain Syndrome (PFPS) or runner’s knee, anterior knee pain is probably a better term because it encompasses a variety of different syndromes that people get involving pain on the front of the knee, usually right around the patella or knee cap. Classically, this results in some popping and clicking when you bend your knee, pain if you press down directly on the kneecap and bend your knee, worsening pain going down (or up) hills or stairs, or when getting up after sitting still for a long period of time. This is the most common cause of knee pain seen in family practice or sports medicine clinics, and is also more common in women. While the exact cause is not known, it is likely a combination of underlying anatomic differences resulting in knee caps that are unstable and don’t glide properly along the femur. This could be due to being knock-kneed, or having a lot of extra movement in your kneecap. This in turn may be due to having a shallow groove for your kneecap to move up and down in, or due to weaknesses or imbalances of some of the muscles in your leg. Excessive pronation may also contribute to improper knee alignment, so consider arch supports and working on running form. Regardless of the individual cause, it is important to realize that each time you run or jump, the forces under your kneecap are approximately seven to eight times your body weight,  so there is tremendous stress to this area. The kneecap cartilage is quite thick, but it still suffers from considerable wear and tear. As a result, keeping a normal weight is a very important part of the puzzle in keeping control of anterior knee pain.

The muscle imbalances in anterior knee pain are partly the same as with ITBS – weak muscles out the outside of your hip (abductors). When these muscles are weak, the entire knee tends to move inwards during activity, increasing the stress on the knee. In addition, weak muscles on the inside of your thigh (your VMO), can cause the knee cap itself to track to the side when it is bent, worsening symptoms. Some people have an extra band of tissue on the inside of your knee called a plica, which can cause pain, and is occasionally treated surgically. In extreme cases of kneecap instability, some people have kneecap dislocations, where the kneecap itself may move all the way to the side after a fall or direct blow, and be very painful and deformed. If you have multiple dislocations, your doctor may consider surgery for stabilization of your knee, but normally run-of-the-mill anterior knee pain is NOT treated with surgery or injections, just with good old-fashioned work. There are some patellar stabilization braces that may provide significant pain relief to some athletes as well, especially if your kneecap is “loose” and you’re having difficulty getting through the strengthening exercises.

Some simple exercises to start and help if you are experiencing anterior knee pain include:

  1. All the hip abductor exercises I described above for ITBS.
  2. If you have a lot of pain, start with straight leg raises while sitting or lying down, to strengthen your quads and hip flexors.
  3. Squats. Squat down pushing your buttocks back, as if you were going to sit on a chair, keeping weight on your heels, and ideally stop bending your knees at about 95 degrees (do not go below 90 degrees).
  4. Stretching of quads, hamstrings, IT band.
  5. Activating VMO. Start with sitting with your legs straight, gently push your knee cap down and outward, then tighten your thigh and feel your kneecap glide back into place. Once you can do this, lie on your back with knees bent about 90 degrees and a ball or pillow between your knees. Slowly kick each leg in turn up to the ceiling for about one minute, and repeat twice.
  6. Single leg balance exercises. Try to do these all the time!! While you’re brushing your teeth, cooking dinner, doing anything standing up – practice standing and balancing on one leg. Try to stand on each leg for at least 30 seconds a time, several times per day, every day. If you want to get fancy, you can start doing some single leg squats, reaching and balancing exercises on one leg, or catching a ball while standing on one leg. But start simple and go from there.

As far as my bout of ITBS that started right before the Boston Marathon, when it flared I basically stopped running and started right back up doing my strengthening and stretching exercises. I still had some pain in my iliotibial band, even with walking, when I lined up at the starting line for Boston, but the weather was perfect, my pain was much improved, and I had worked so hard that I was not going to turn back. I’m not normally a very emotional person, so I was surprised to blink back some tears as the starting gun went off. I finished the marathon, quite a bit slower than I was originally planning, but without any major injuries or problems. I had incredible muscle soreness afterwards and took the next few weeks off of running, but continued my ITB exercises so that when I started running up again I was pain free, strong, and stable.

Good luck everyone!

ILONA BARASH is a physician, climber, and runner living in San Diego, California whose life has been a balancing act between athletics and academics. She climbed El Capitan in Yosemite and did first ascents of alpine climbs north of the Arctic Circle in Alaska while earning a PhD in muscle physiology… more »

Comments

  1. Julia says:

    While running the Chicago Marathon, Oct.. 7th, I experinced ITBS. I’d never had an issue with it before, but think maybe I was compensating for Plantar Fascitiis which had set in in August. I have taken 4 months off. I cross train 5 days a week and have done all the strengthing exercizes Dr. Barash suggest along with wieghts which focus on glutes and abductors. Prior to the marathon, I ran 30 miles/week. I have recently tried to ease back into running and increased to a 2.5 mile run, but felt pain the following day so I laid off another week. Is the Dr. suggesting it is ok to contiinue to run with some ITB pain? I have none while running now, just after.

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  2. Theresa says:

    I’m not a runner, but I have trouble with my knee, including frequent lateral pain. I don’t have a good mental picture of the third abductor exercise you described. Could you break it down for me a bit more, please?

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  3. Tara says:

    I’ve experienced knee problems related to the symptoms of Anterior Knee Pain, not from running, but from yoga. I would get pain from sitting too long (like at the movies or on a plane), snapping and clicking when walking down stairs and could not sit with my legs cross for any length of time. I think the yoga overstretched my knees, tendons, ligaments. I took up weight training with squats, leg press and now lunges and the knee problems are completely gone, COMPLETELY GONE, in a month of progressively heavier weights. I can run short distances without pain and walking long distances with no pain afterwards. I kept being told to strengthen my quads and that advice turned out to be quite accurate.

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  4. Anno says:

    Jim Johnson’s 9 dollar book about knees. nuff. I have bad knees have done yoga for 40 years and never had knee problems tilll I started running, down hills. If yoga gives you problems schedule a one on one with an insttructor or accept that you don’t have a yoga brain (as I have accepted that I do not have a pilates brain…all the counting panting and flapping)

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  5. ilona says:

    Julia – nice job working through the ITBS pain and rehab process. I would say that it is OK to run through the pain if you have a specific goal you are raining for, but if it hurts, you are prolonging the recovery process. It sounds like you are very close to recovering completely, so I would hate to have you start back to soon and have a worsening injury. You are not doing permanent damage by running on it when it hurts, but you are delaying the recovery process.

    Theresa – I’ll try to take some pictures doing the exercise to make it more clear sometime soon, but basically you have the loop around your ankles or around the balls of your feet, and are taking steps sideways. You start with your feet about 1 foot apart with slight pressure on the band, step your left foot to the left about 8-10 more inches stretching the band, then move your right foot to the left so you are again 1 foot apart. Repeat the process going about 10 steps in each direction. Its important during the exercise to keep your hips square and your upper body still so you don’t lurch your hips in either direction, and have a fairly constant pressure on the band at all times, never letting it get slack.

    Tara – glad your anterior knee pain is improving. as runners we tend to neglect strength training, but it is a key aspect to staying healthy.

    Anno – pain with running down hills is quite classic for anterior knee pain. Glad you found a system that works.

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  6. Ruth says:

    My knee has been bothering me while trail running, skiing & cycling. It has taken me a few weeks to figure out what is wrong with my knee and how I injured it. I have “Pes anserine bursitis”, an inflammatory condition of the medial (inner) knee at the anserine bursa, a sub muscular bursa. I believe I injured it during a 3 week period of tree felling, firewood cutting & very heavy lifting. Rest, stretching and yoga are helping. Do you have any other suggestions to speed up the healing process? I don’t make a good couch potato.

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  7. I am a 25 year veteran to road racing, 5k to marathon. At 49 years old I am still running 6:20 pace…..I am also a certified Chi Running instructor and got that cert cause it made so much sens to bring my 10 yr yoga practice to my running! The focus on alignment, efficiency and relaxation of Chi Running would really help with ITB!

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  8. Elizabeth says:

    Have been running for just 4 years, competed 8 half marathons & numerous 5k’s. Paid close attention to shoes, cross training & seeing a Chiro regularly. At 57 yrs young, I was in training for my first full marathon! Knee pain 2 weeks prior to marathon had me seek MD advice. Diagnosis; meniscus tear, bilateral! Surgery was the treatment. I’m still mending & am fearful I may not be able to run a full marathon. Listen to your pain, it’s telling you something.

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  9. Julia says:

    Thanks for the reply and advice Dr. Barash!

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  10. Mandy says:

    It’s hard to say this because it goes against what most athletes believe (especially hard-headed runners… me being one of them!) but “strengthening” the area that’s in pain will not correct the problem. The problem is a force-absorption issue and until the neurological disfunction is corrected, you’ll have no permanent relief. The BRAIN controls everything. Muscles are only “pawns” in the way your body works. Your muscles are not absorbing force correctly because the brain is not connecting to those muscles properly. (I can go into a LONG lecture about how this happens… but in short, we screw up what God created :) “Strengthening” and “stretching” those areas only works to deepen compensation patterns and incorrect movement patterns. Ask any athlete who treated an injury’s physical symptoms and see if the pain (or another pain) comes back within 3-6 months. You haven’t fixed the problem. In the brain. Where it all begins. Seek out therapists who treat athletes neurologically and you’ll have the answer to you pain relief, I promise! They are out there – you just have to look!

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  11. ilona says:

    Ruth – it sounds like you are doing the right things, as long as you are getting better. Sometimes a corticosteroid injection in the pes anserine bursa helps if you are struggling.

    Robyn – I’ve been been meaning to try Chi running, I’ve heard wonderful things about it.

    Elizabeth – good luck after your surgery!

    Mandy – I’m glad you found relief from your pain and symptoms, different treatment modalities work differently for everyone.

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  12. Helena says:

    Hi! Thanks for posting these. I’ve been doing the suggested exercises, along with some similar ones described in the last issue of Runners World, regularly since you posted them. Pleased to report that I’m already gaining strength! Hopefully this will translate to better running … And tighter glutes would be nice, too! Anyway, thanks again.

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  13. ilona says:

    Helena – so happy you hear your are making progress! It can be a slow process, but it does work. probably the hardest part of a program like this is keeping it up even when you are feeling good (speaking from experience :). Nice work, and good luck!

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  14. Caroline says:

    I am marathon runner and triathlete. Last year was good one placed,in a few local tri and qualified for Boston. I felt good all year. I am 49 and my next big goal is 1/2 iron man at end of August with some smaller races, before including the Athleta Iron Girl. After October marathon I took it easy. Winter training brought on knee pain that radiates from lower back ..back of leg. Done chiropractor, some pt, X-rays and MRI to come..frustrated as no one can figure this out and cannot train to the level I am used to. I get knee pain after about 3 mile running but can ride 30 with some pain. Nerve? Piriformus? Your thoughts?
    Thanks

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  15. ilona says:

    Caroline –
    Sounds like sciatic nerve pain vs glute dysfunction, versus SacroIliac Joint dysfunction, although difficult to diagnose without seeing you in person. Try and see a good PT or sports medicine doc that specializes in runners injuries – it is pretty common for women runners your age and experience to have significant imbalances in the gluteal muscle activation, and you may have to retrain yourself to use your gluteus medius more effectively. As I mention in the above article, knee pain in runners is often due to weak and/or uncoordinated glutes, and if its sciatica or obturator impingement this will help retraining them will help. Its probably not piriformis syndrome by itself, although that could be contributing. One easy test: can you keep your pelvis level as you step down off a box? if not, one likely etiology is weakness and incoordination of your glutes…

    Good luck!

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  16. Jen says:

    This is the most comprehensive explanation of an issue I’ve been dealing with for a while now. Now 44, I had arthroscopic knee surgery when I was 18 (cartilage). Prior years of gymnastics had taken it’s toll. Was told it was Chondromalacia and chronic. I spent most of my 20′s and 30′s sporadically exercising and having kids. Finally got back into serious fitness about 6 years ago. Most of my workout consists of fitness kickboxing, step, running, strength training and yoga. The knee was relatively fine until about a month ago.

    I’m doing lots of step/plyometrics and experiencing inflammation, decreased flexibility (can’t get my heel to my butt in traditional quad stretch) and pain. I had a Chiropractor tell me my knee is “pretty worn out” and may need replacement surgery some day. I’d rather take a strengthen and stretch kind of approach for as long as I can.

    I had a feeling that my recent weight gain might be part of the problem and your article confirms this. Thank you for bringing it into the discussion!!! Even more motivation to shed this last 10 lbs.

    Thanks so much!

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  17. Heather says:

    Hi Ilona,
    Thank you for this excellent article on strengthening the knee! I’m an avid skier (100+ days per year) and also a runner. Particularly when skiing, my knees can take a beating. I’ve had my share of knee troubles and accompanying knee surgeries over the years, although my knees have actually improved since I began running about 4 years ago.
    I’ve only been following your regime for three weeks, but I can already feel an improvement in the performance of my knees. While my quads are absolutely strong enough to do squats (months of skiing big mountains each winter) , I’ve never actually been able to do more than two or three in a row due to knee pain. I just completed three sets of 10 squats this morning — wow!
    Yours is the first regime that has actually improved the functionality of my knees. Thank you so much for this excellent article!
    Heather

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  18. Renee says:

    Thanks so much for this! I’m dealing with knee pain that came on half way through my last long run & 2.5 weeks before my next 50k! I’m kind of freaking out over here & haven’t run (or done much of anything, to be honest) since said run. I guess I’d better get myself into the gym!
    Thanks again.

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