Runners Knee. What Is Iliotibial Band Friction Syndrome And How Can We Treat It?

This article is written by Scott Newton and Noel Thatcher from The Running Works Sports Clinic. Scott is a 2.37 Marathon runner and experienced physiotherapist specialising in running biomechanics. Noel is a distinguished member of the England Athletics Hall of Fame, MBE, and winner of 5 gold Paralympic Gold Medals!

What is Iliotibial band friction syndrome?

Have you suffered from pain on the outside of your knee which gets worse the further you run? Have you experienced pain when bending or stretching the knee- especially when moving from a static postion? Then it is likely that you have experienced one of the most common causes of knee pain in runners, iliotibial band friction syndrome (ITBFS) aka 'Runner's Knee'.

Who gets it & what causes it?

ITBFS is primarily with overuse, caused when runners ramp up their training mileage too suddenly. If you substantially increase the frequency, duration or intensity of your running you could be putting yourself at risk.

A lack of variety in training route, pace or even footwear may also contribute to the development of excessive stress or irritation of the ITB on the bony prominence on the outside of the knee & the underlying bursa.

Typically, we see yearly peaks in the number of patients presenting with ITBFS, coinciding with periods where those training for Spring and Autumn marathons will reach their peak volume & intensity of training. Runners will suffer from several weeks of worsening pain, which has failed to respond to rest before they approach the physio for treatment.

How is it treated?

Effective treatment of Runner's knee or ITBFS requires more than rest, foam-rolling and the odd few strength exercise.  Stretching tight areas and strengthening muscles play an important part of the rehabilitation process, but to get sufferers back to running (and keep them running) you need to address training load and running technique.

Traditional management rationale from a medical or physiotherapy perspective (e.g. rest, stretches, knee & hip strengthening exercises) fails to address biomechanical risk factors associated with ITBFS.

Addressing Load Management (aka training error) 

Given ‘Runners Knee’ is primarily caused by ‘over training’ the onus should be you to monitor your own aches and pains in response to changes in training load. In simple terms, all ‘niggles, aches and pains, particularly those that recur should be considered as signs and symptoms of a potential injury.

However, we appreciate that it’s not that easy. All runners just just want to run- we’re all clear sign that we are overstepping our bodies capacity to adapt to the stress of a training load. In simplistic terms aches and pains, particularly those that recur should be considered as the signs & symptoms of a potential injury

Unsurprisingly response to training is a very individual factor & is why runners who determinedly stick to generic training programs (ignoring niggles) all too often end-up injured.

The first point to is the failure to monitor or ensure that runners themselves monitor for persistent niggles in response to their training load.  In simplistic terms niggles (aches & pains), particularly those that recur should be considered as the signs & symptoms of a potential injury which occur when we overstep our body's capacity to adapt to the stress of a given training load.  This commonly happens when increasing mileage too rapidly or when introducing more hilly terrain.  

Educating (aka coaching) runners to self-monitor their response to training is therefore vital so that they are able to recognise when they need to adjust their training program, not only to avoid injury/re-injury but also to recognise when it is safe to step-up training to optimise performance.  Properly qualified coaches are arguably best placed to effectively manipulate training loads & impart these skills to runners.

Running technique, gait re-training & the barefoot/forefoot/rearfoot/minimalist debate...

The second is failure to address running technique.  All too often runners presenting with ITBFS are examined in every position with the exception of running.  It is possible to have excellent range of movement & strength in the knee & lower body, but to run in a way that places more stress on the ITB, a classic example would be those runners who have a cross-over gait pattern (e.g. run as if they are following a tight-rope).  It would seem logical to examine how a runner with ITBFS actually runs, just as it would be to correct a faulty golf swing or tennis serve, but all too those managing running related injuries fail to carry out an assessment of running gait & do not recognise key features of gait which may predispose to certain running related injuries.  For example, tibial stress fractures have been linked particular running styles/patterns of movement.  

Many common running technique flaws (e.g. over-striding, slow cadence) can be picked up with 2D gait analysis & corrected using simple ‘cues’.  There is growing evidence that gait re-training, using verbal & visual cues, is an effective way of adjusting where stress is applied to muscles & joints of the lower body when running.  A recent study, for example, showed that increasing step rate could decrease the force applied to the knee by as much as 15% per mile (Willson, 2013).  In our clinical practice, we have seen patients with knee pain whilst being assessed report an immediate reduction, & occasionally, complete resolution of their pain with real-time gait re-training.

Whilst the jury is still very much out as to the 'optimal' running style or technique, & how footwear may intrinsically influence these factors; there is a growing body of evidence that shows the way in which we run can influence how & where we apply load to the muscles & joints in the lower body.  With appropriate knowledge of how manipulating running characteristics such as cadence, step-length/width & even terrain, it is possible to manipulate how load is applied to the body.  A commonly used cue when runners experiencing ITBFS is to ask runners to 'keep their knees apart & keep their hips high'.  This can reduce the degree of excessive rolling in of the thigh at footstrike which can result in increased friction between the ITB & the underlying prominence of the knee (thought to be why ITBFS develops).  

The video clips below illustrate, the effect that verbal cuing can have on running style.

Noel Thatcher Pre-Verbal Cues

Noel Thatcher Post Verbal Cues

A word of warning...

Although gait re-training can be a very useful treatment strategy for ITBFS (& other running related injuries) it requires careful thought as it will mean that more stress will be applied to other areas of the body, such as the ankle/foot & Achilles.  Structures which are tasked with taking on more load will need time to adapt to new stresses so they do not become the next problem.

Therefore the aims & objectives of any gait re-training requires careful consideration & evaluation before being integrated progressively, as a component in an overall training program.  Regular review & coaching feedback, particularly in the first few weeks of gait re-training can be invaluable to minimise the risk of transferring one injury for another.

Get better by running shorter distances, faster & more often...

Despite sounding instinctively counter-intuitive, running faster & more frequently, but for less time can be an effective way of rehabilitating.  This is because ITBFS is a problem of repetition & overuse causing irritation to the structures around the outside of the knee.

Therefore running more frequently may allow us to more rapidly assimilate more efficient running styles by practicing gait re-training cues frequently (frequent repetition is key to learning any new movement pattern/running style).  Training at a slightly higher pace will ensure that most of us will naturally increase our stride rate, which in turn will lessen any over stride (which applies more stress to the knee). Finally incorporating a variation of pace in training will subtly vary where load/stress is placed on the knee and lower body.  All of which are likely to be helpful in reducing the symptoms of ITBFS if applied carefully.

Not a recipe...

Hopefully this article has offered a few new thoughts & perhaps some slightly different perspectives on how ITBFS & running injuries more broadly may be managed through the use of sound coaching principles.  Running injuries, like most overuse injuries are always multifactorial & optimal management requires a thorough assessment of the various factors & nuances that contribute to them, which in our opinion is best delivered by qualified individuals who are passionate about running & understand running.