Injuries Part 1

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There is nothing more annoying than being injured. I know. Currently I'm suffering from an ITB issue - excruciating pain on the outside of my knee when I try (try being a very poignant word) to run down hill. Frustration at not being able to run in the hills seems even more frustrating as I've only been living in Derbyshire for the past 3 months. Seeing the hills so close is mighty tempting.

And that is where I went wrong. Too much, way too soon. The excitement of having hills on my doorstep overrode the common principle of increasing mileage slowly (10% per week is a good guide). So for me coming from running not that far, maybe 8km at best in London on the roads mostly, 10km in the fells was a bit optimistic. I for one should have known better. Now I pay the price with a slow recovery. I think this was the same over-excitedness that takes over common sense of others when they set off on a new challenge.

Now I'm one for being overly cautious about returning to running too soon, though I think I'm in the minority - most people preferring to return to training too soon and doing more damage than they had originally - and a subsequently longer period of inactivity. Given this, it always jumps out and surprises me when the pain kicks in again after what seems a remarkably long rest period. So where am I going wrong. It is slowly dawning on me that rest alone is not sufficient to get me back to fitness. I need to focus my recovery on not only rest, but also strengthening my glutes and my left psoas (hip flexor) which was considerably weaker than on the right.

So what are the possible factors that can contribute to or lead to an injury? We can break that down into two parts: internal and external factors. Internal factors, or intrinsic, are all things that are within us, inside our body or the stuff that is our natural make up. We can change some of these, and some we can't. In this category we have fitness, technique, body composition, anatomical variants, gender, age, past injuries, and finally psychology. The factors that may contribute to whether we get injured which are external, or extrinsic are those which come from outside of us: the environment, equipment we may use and the training and competition we undertake. It's safe to say we have a much greater degree of control over the extrinsic factors - but equally they're all interlinked.

I've given you an introduction the issues surrounding injuries, with some insight into the experience I've been through recently. I did my first rehab running session yesterday, going out for 30 minutes but with 5 mins warm up, then 1 min walk/1 min run for 9 sets, and the remainder of the time walking to cool down. I'm pleased to report that there was no pain in my knee and with the exception of it being a hot and humid evening the run was very pleasant. There's been plenty of foam rollering and sports massage too, which both contribute to a good rehab strategy. For those of you who are interested, I'll write more about the extrinsic and intrinsic factors soon.

Lynne

ITBs (Illotibial Band Syndrome)

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ITB syndrome is relatively common among the runners and triathletes that I have treated. It's described variously as a sharp pain on the lateral (outside) edge of the kneecap, so painful that its like someone is poking a hot pin in there and twisting it around. It can also be felt further up the Band, toward the hip, but for this article, Im going to concentrate on the knee problem.

The distal (bottom) part of the ITB, and potential painful spot.

As you would expect, this tends to have an effect upon running style, generally a pronounced limp, followed swiftly by a walk, and then a phone call home to get picked up.

For those who don't know, the Illiotibial Band is a wide strip of collagen fibre stretching from the hip down to the knee. It attaches at proximally (at the top) to the fascia around the hip and (more importantly) to a muscle called the Tensor Fascia Latae (hereafter known as TFL). The TFL is kind of embedded in the fascia as opposed to being the controlling muscle of it.
Distally (at the bottom), the ITB attaches to the fascia around the kneecap on the lateral (outside) of the knee. It is here that the pain from ITB syndrome usually hits.

The ITB (in blue) and the TFL (in Black)

Why does it happen?!
I'm going to have to split this up into 2 sections, Fire and Smoke.
Fire-
The actual underlying reason this happens is based in the gluteal region, (your bum). As you walk/ run, there are a series of 6 muscles called the Deep 6, (or lateral rotators), their job is to keep the leg in the optimal position with the hip. In effect they act like a guy rope to keep the leg in line.
Just for reference, these muscles in this group are the Piriformis, Obturator Externus, Obturator Internus, Quadratus Femoris, Gemellus Inferior and Gemellus Superior.

The Deep 6 (the observant of you will notice I have only drawn 5 on there, the Obturator Externus is best drawn on from the front- and a bit more difficult to visualise from the back- so to prevent confusion, I refrained from drawing it.)

 Other muscles involved in this action are Gluteus Maximus, Gluteus Medius (both in your bum), also Psoas major, Sartorius and Iliacus, but we shall skip over the last few for the time being.

Now, if these muscles are not working as they should, ie. they aren't strong enough, or they are inhibited (as most of the triathletes I have seen), they are not able to stabilise the leg in the correct position as you walk/run. The only thing that the body can really do at this point is use the ITB - a length of non-contractile tissue - to hold the leg - and therefore the knee - in the right place.

So instead of a group of 10 or so muscles keeping the leg in line, the body is relying on a single piece of collagen - whose original job is to keep the knee-cap in the right place - to keep the whole leg in line with the hip.

All the muscles around your bum. Its quite packed in there, if they aren't working properly, or are inefficient, its pretty obvious that something is going to have to give. Generally, its going to be the ITB.

Smoke
We know that the ITB is now doing the vast majority of the work because of the inefficiencies of the muscles in the bum. The ITB is made up of collagen - which is an awesome substance. It responds to stress by getting thicker and tighter. So, as you pound your way down the road (or the fell), the ITB is getting thicker and tighter all the time, if it is that tissue that you are relying upon to keep the hip, leg and knee in line, it's going to get tighter. As it does so, it begins to pull the kneecap laterally (outwards), and can have the effect of making the kneecap track incorrectly - wearing out the inside of the kneecap - but the beginnings of pain are generally the feeling of tightness on the lateral (outside) edge of the knee- just where the ITB attaches to the fascia.

Treatment

A lot of people swear by foam rollering, or "stripping" the ITB, which is as painful as it sounds. If it has gone far enough, the collagen has plasticised (my words) itself into a form that is supporting the knee and the leg. The stripping of the band is necessary to re-educate the collagen so that it loosens off and doesn't pull on the kneecap anymore.

A foam roller of the foam variety

The problem with this is that its taken a few years to get into this state, and just rollering it a few times isn't going to make it just go away. You have lengthened it a bit, but as stated, its like plastic. It needs a long time to go back to the way that it was. If you have ITB pain, you are going to need to be using that roller for quite some time before it gets educated to go back to the way it should be.

A foam roller of the improvised variety. It doesn't NEED to be Rescue Ale, but it benefits Woodhead MRT if it is.

 If you do go to someone and they start digging into the ITB in a way that makes your eyes bulge and your throat go hoarse, they should also be looking at that muscle we spoke about earlier- the TFL- its a small muscle, embedded in the ITB up toward the hip. This muscle helps create tension in the ITB, and if the collagen band itself is being treated, the muscle which assists it should definitely be looked at as well. 

However.
If you just get the ITB "stripped" thats just the start. The Lateral Rotator muscles need to be trained to work better. If they don't do their job, the ITB will continue doing more than it should be doing, and hey presto, it will come back, and you'll do the whole thing all over again.
If you see a physio/massage therapist who just does your ITB and sends you on your merry way, get another one. They are using you as a cash cow.
They should be looking at the musculature around the hip, the muscles may be weak/inhibited, they may be biomechanically inefficient and need stimulating massage as well - (just as a warning, this may be as uncomfortable as the ITB stripping). They should also give you ideas as to what to do to strengthen the muscles in order to help reduce the pain in your knee.

Examples of things you could use as a Roller for your ITB. (I didnt have a 2 litre coke type bottle, but you could use one of those as well, even better if its pressurised and you don't have to drink it)

Golden Rule 1
If you have ITB syndrome, get it seen to by a professional, the quicker you get it sorted, the quicker you will be running pain free, and the less chance you have of the injury compounding.

Golden Rule 2
If you talk to a professional about knee pain, and you HAVEN'T hit your knee - but they only look at the knee, go to someone else. If there hasn't been a contusion to the knee structure itself, the issue is far more likely to be in the hip or the foot. And if these are not looked at in some detail, well, thats a bad thing.

I hope thats been a decent intro into Illiotibial Band Syndrome, what it is and why it happens. If you have any comments, I'd be happy to hear them.

A portrait of the artist hard at work