Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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So, a very common issue I see in runners is iliotibial band (ITB) syndrome. In a nutshell, it involves excessive rubbing or friction of the ITB along the greater trochanter or lateral femoral epicondyle. It is more common along the lower leg just above the knee and typically worsens with increasing mileage or stairs.
The ITB is essential for stabilizing the knee during running. Several factors may contribute to increased risk for this problem:
- Muscle imbalances (weak gluteus medius and deep hip external rotators)
- Uneven leg length
- High and low arches
- Increased pronation leading to excessive tibial rotation = friction of the band
- Improper training progression
- Faulty footwear
- Poor running mechanics
- Limited ankle mobility (specifically dorsiflexion)
- Tightness in the tensor fascia latae (TFL) and glute max
Related information on this topic include a 2010 study published in JOSPT on competitive female runners with ITB syndrome:
Click here to see the abstract of the study
Click here to read an earlier blog post analysis of the above research article
Common signs and symptoms include stinging or nagging lateral knee pain that worsens with continued running. Hills and stairs may further aggravate symptoms. Some runners even note a “locking up” sensation that forces them to stop running altogether. How do I treat this?
Often, people assume hip and knee pain begin and end in those respective joints. While this can be the case, the truth is the ankle may also have a say in the matter. In my practice, I often see gait deviations, IT band issues, patellofemoral pain and many other issues related to ankle stiffness or soleus issues.
In assessing athletes, runners and weekend warriors, I often pick up asymmetries when measuring closed chain ankle dorsiflexion. I have even observed people who have active dorsiflexion within normal limits while seated on a treatment table, but once they become weight bearing things change. Even small differences can dramatically affect the body as the brain will find a way to get the motion it needs to squat, run, lunge, etc.
This often involves a compensatory pattern at the knee and/or hip joint. So, to that end, I recommend several strategies to improve mobility. I am currently doing a three part series on this for PFP magazine to provide some effective exercises to improve ankle and soleus mobility. Click here to read the latest column.
Below is a sample video of the wall touches I use to improve ankle motion after mobilizing the soft tissue.
Typically, I advocate doing 1-2 sets 10-15 repetitions. Using the wall allows clients to have tactile feedback and a target to focus on. This is a simple, yet effective way to gain motion in a loaded closed chain fashion as the hip, knee and ankle flex together in running, landing, squatting, lunging, etc.
If you are curious how I assess side-to-side differences, click here to read my initial column on assessment. I hope these tools enhance your training and/or those you work with.
Unearthing the cause of anterior knee pain and ridding our patients and clients of it is one of the never ending searches for the “Holy Grail” we participate in throughout training and rehab circles. I honestly believe we will never find one right answer or simple solution. However, I do think we continue to gain a better understanding of just how linked and complex the body really is when it comes to the manifestation of knee pain and movement compensations.
We used to say rehab and train the knee if the knee hurts. It was simply strengthen the VMO and stretch the hamstrings, calves and IT Band. Slowly, we began looking to the hip as well as the foot and ankle as culprits in the onset of anterior knee pain. The idea of the ankle and hip joint needing more mobility to give the knee its desired level of stability has risen up and seems to have good traction these days.
Likewise, therapists and trainers have known for some time that weak hip abductors play into increased femoral internal rotation and adduction thereby exposing the knee to harmful valgus loading. So, clam shells, band exercises and leg raises have been implemented to programs across the board.
Single Leg Resisted Hip External Rotation
As a former athlete who has tried his hand at running over the past 5 years, I have increasingly studied, practiced and analyzed the use and importance of single leg training and its impact on my performance and injuries. As I dive deeper into this paradigm, I continue to believe and see the benefits of this training methodology for all of my athletes (not just runners).
As a therapist and strength coach, it is my job to assess movement, define asymmetries and correct faulty neuromuscular movement patterns. To that end, I have developed my own assessments, taken the FMS course, and increasingly observed single leg strength, mobility, stability and power in the clients I serve. Invariably, I always find imbalances – some small and some large ones.
What are some of the most common issues I see?
It is common knowledge in the medical community that treating patellofemoral joint pain (PFJP) is one of the most frustrating and difficult tasks to complete as there appears to be no standard way to do so. While clinicians strive to find the right recipe or protocol (I don’t believe there is just one by the way), researchers press on to find more clues.
A new article released in the April 2011 Journal of Orthopaedic & Sports Physical Therapy seeks to bring clarification to a particular exercise pattern commonly used in rehab circles. The three exercises they looked at were:
- Forward step-up
- Lateral step-up
- Forward step-down
In the study, the authors looked at 20 healthy subjects (ages 18-35 and 10 males/females) performing the separate tasks with motion analysis, EMG and a force plate. The goal was to quantify patellofemoral joint reaction force (PFJRF) and patellofemoral joint stress (PFJS) during all three exercises with a step height that allowed a standard knee flexion angle of 45 degrees specific to each participant.
Key point: Previous research has been done to indicate that in a closed chain setting, knee flexion beyond 60 degrees leads to increased patellofemoral joint compression and this may be contraindicated for those with PFJ pain or chondromalacia. Also keep in mind that most people with PFJ complain of more pain descending stairs than ascending stairs.
In the study, the participants performed 3 trials of 5 repetitions of each exercise at a cadence of 1/0/1 paced with a metronome. The order of testing was randomized for each person. The authors used a biomechanical model to quantify PFJRF and PFJS consisting of knee flexion angle, adjusted knee extensor moment, PFJ contact area, quadriceps effective lever arm, and the relationship b/w quadriceps force and PFJRF.
Now on to the results……
Wow! It has been a busy two weeks for me. I have been putting the final touches on a DVD and writing a ton of articles lately. I just returned from speaking for Power Systems at a Total Training Seminar in Missouri in late March. It is always interesting speaking and hearing other presenters.
There is usually no shortage of controversy and conflicting opinions either when it comes to fitness and training. One speaker mentioned that it is perfectly okay to allow the knee to go over the toe with exercise. In fact, this presenter said it was desirable to maximize training. My talk (later on) was on bodyweight training for a healthier knee.
Naturally, I was asked what I thought about the earlier comment. My answer was “it is complicated.” I am not sure that is what the audience wanted me to say. Pressed again later on, I acknowledged that in a repetitve training environment, lunging and squatting with the knee over the toe is not something I recommend. However, if I am retraining a client to be able to descend stairs one foot over the other, the knee does in fact move beyond the toes.
So, there are times in life, where we need to think outside absolutes and adjust our thoughts and training to meet the needs of people at a current time and space so to speak. The real trick is knowing the client, their medical condition, their needs and measuring the response from the body. I hate protocols because no two people are the same, nor do their bodies heal and react the same way.
But, let’s get back to the knee. I talked about assessing the knee and then integrating the “right exercises” to not only correct dysfunction but also to improve fitness and performance. If you think body weight training is useless or for sissies, you may want to think again particularly if you like to run and have any issues with patellofemoral pain (most women do have PF pain or early arthritis).
Consider the research from the Journal of Orthopaedic and Sports Physical Therapy in 2003 where Powers et al. determined that PF joint forces are significantly greater with external loading versus bodyweight only in flexion angles begining at 45 degrees during eccentric loading (lowering down while peaking at 90 degrees) and concentric loading (rising up) at 90 and 75 degrees. What does this mean for you?
Essentially, if you are a runner and suffer from PF pain, you may want to limit deeper range of motion with squatting and/or consider limiting the amount of external loading as well. Even better, you should be doing single leg training keeping this same information in mind. Training is an exact science and most people get it wrong all the time. That is why I am currently working on a Fit Knees DVD series to give trainers and consumers relevant and science based information to direct their training for optimal health and performance.
I just finished volume three in this series and it is ready for official release this Friday. If you are a runner and want a blueprint to train for injury prevention and peak performance, this DVD is for you. Or, if you are a runner who is currently injured or has been plagued by overuse injuries, it is still for you as I have a complete progressive rehab series on the DVD to get you back up and running again.
As a runner myself, I have put these strategies to good use with much success. I thought it was fitting to relase the DVD this week as I prepare to run my 4th half marathon in Charlotte this weekend. Below you will see the product display.
As a blog subscriber or reader, I am offering you $10 off the normal price of $34.95 through midnight Saturday. Simply visit www.fitknees.com and use the copuon code BFITRUN (all caps) at checkout. I am confident you will find it valuable as it covers training from A-Z with warm-up prep, foam rolling, balance training, strength and power exercises, rehab and stretching. It is 65 minutes of power packed content. Here’s to healthier knees and happy running!
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