I want to take you back to September of 2014. I was two months out from running my second marathon, the New York City Marathon, when marathon training came to a standstill because of a paralyzing pain in my knee. After a failed $250 appointment with an orthopedic doctor who told me to stop running until my knee didn't hurt, I needed a solution that wouldn't rob me blind. So I made an appointment at the best Physical Therapy clinic in New York City, Finish Line Physical Therapy. I was scheduled the next day with Mike Riccardi who had me running pain free within 2 months and has helped me stay injury free ever since.
Running injuries are inevitable when you're a runner because for most of us, we're running for fun. Our goal is to finish whatever race or goal we set out to complete and many of us over train or run with incorrect running gait. The best way to treat injuries is to prevent them! I want to re-share a piece Mike wrote for Run, Selfie, Repeat back in 2014 called "Let's Talk Running Injuries With My Physical Therapist Mike Riccardi" because in addition to going more in depth to what we talk about in BQ or Bust 011 How I Met Your PT, it has some insightful information about common running injuries. TAKE IT AWAY MIKE!
Kelly first came in to see me about 5 weeks before the NYC marathon. Like other patients that come in around the same time, Kelly's biggest fear was that she shouldn't be running anymore. She had felt some pain a few weeks prior to coming in and per her doctor’s recommendation she took a week off. Many runners have this "If I just rest it'll go away" mentality but rest only gets rid of some of the initial inflammation, it doesn't truly address the underlying causes of pain. So, when she tried running a week later she started having right knee pain.
After doing a quick exam on the table I found that Kelly, like countless others, had some common issues including: decreased hip mobility and decreased outer hip strength. When I had Kelly do some more functional activities like squatting, single leg squatting, balance, step downs, etc. I saw how those issues affected her movement. Finally since her issue came from, and was exacerbated by, running I needed to watch her run. Again, some of the limitations I found on the table and with the functional movements showed up in her gait analysis: over-striding, decreased hip extension, increased hip drop while on one leg (trendelenberg), as well as a few other things but those were the biggies at the time.
Immediate treatment included giving Kelly some cues while running to improve her form and decrease the amount of force going through her knees, manual techniques (which Kelly will probably describe as complete and utter pain), foam rolling to help loosen up her hips (more pain), stretches for her hamstrings and hips flexors, as well as some strengthening exercises while we still had some time before the taper period. As we got closer to the marathon we focused most on getting her pain down by switching largely to manual based treatments with the addition of functional stretching and foam rolling. Now that it's post-marathon I've discussed with Kelly the importance on continuing to come into therapy to work on strengthening exercises that will help resolve her knee pain completely, and more importantly, keep it from coming back.
Running is an inexpensive form of vigorous-intensive physical activity and can be done anywhere and at any time. However, running may cause various overuse injuries, especially in the legs. Various studies have reported on the prevalence and incidence of running injuries occurring during training or races, with injury rates varying between 25% and 65%. The most common overuse injury in runners is patellofemoral pain syndrome (PFPS), commonly called runners knee, followed by ITBS.
Patellofemoral Pain Syndrome (PFPS)
PFPS, commonly referred to as runners knee, tends to present with pain around the kneecap with activities stressing the patellofemoral joint such as squatting, prolonged sitting, stairs, and running. A number of various causes of PFPS have been suggested including muscle imbalance and weakness, overuse, soft tissue tightness, and poor lower limb alignment and mechanics.
Previously, treatment strategies focused on knee strengthening exercises. These have shown to improve pain, however, a shift towards hip based strengthening exercises and programs that combine the two have been shown to be more effective than knee strengthening alone at reducing pain and improving function in people with PFPS. A strength deficiency in hip abduction, external rotation, and extension has been documented in females. Therefore, proximal strengthening of abdominal, hip abductors, and hip external rotator muscles has been shown to result in a significant improvement in PFPS symptoms. Abnormal foot pronation also exacerbates PFPS and therefore strengthening of the dynamic support of the medial longitudinal arch may be beneficial, as well as the use of semi-rigid orthotics.
PFPS Treatment Options
A multimodal physical therapy approach including a unique and specialized strengthening program, stretching and foam rolling techniques, and manual treatment are the main aspects of current conservative PFPS treatment.
Iliotibial Band Syndrome (ITBS)
ITBS is the most common running injury that occurs on the lateral (outside) part of the knee. It is a non-traumatic overuse injury caused by repeated knee movement that causes irritation in the structures around the knee. The incidence of ITBS in runners is estimated to be between 5% and 14%. The syndrome results from rectified friction of the ITB over the lateral femoral epicondyle. The ITB move anterior to, or in front of, the epicondyle as the knee extends and posterior, or behind, as the knee bends,
The main symptoms of ITBS is sharp pain or burning in the lateral knee. Patients typically start running pain-free, but develop symptoms after a reproducible time or distance. Initially, symptoms subside shortly after a run, but return with the next run. Patients often note that running downhill, lengthening their stride and sitting for long periods with the knee in a flexed position aggravates the pain.
Three main factors were investigated with regard to the etiology, or causes, of ITB.
1. The strength of the hip abductors.
Hip abductors are the muscles on the outside portion of the hip.
In addition to certain leg movements, they act to stabilize the pelvis while standing on one leg. Considering running is essentially jumping from one leg to the other, they are pretty important.
Some of the articles had conflicting evidence regarding if hip abductor weakness has a role in ITBS or not.
One study showed that when runners with ITBS first struck the ground, they displayed higher peak hip adduction angles, greater peace knee internal rotation and femoral external rotation, and remained more adducted throughout stance (think of it like running on a tightrope) compared to matched subjects without symptoms.
3. Training and Shoes
Most runners with ITBS spent more than 90% of their training time running long distances at a low speed. Knowing when a pair of shoes need to be retired is incredibly important, as is making sure you're getting the right shoe for you. Don't pick a shoe just because it looks nice but make sure it is the shoe your foot and running form needs. See a specialty shoe store that knows what they're doing and can help you find what's right for you. One store I recommend to NYC runners is "Brooklyn Running Co." in Williamsburg.
Common treatment strategies of ITBS
Common treatment strategies of ITBS involve alteration of running form, manual treatment from a physical therapist, hip flexibility exercises/ stretches, hip abdcutor and glute strengthening, rest, ice, pain medication, and foam rolling. Unfortunately, there is still conflicting evidence around the best treatment strategy for ITBS. It is rarely the result of a single issue so it's important to talk to a physical therapist who will be able to determine possible underlying causes that may contribute to poor running form and will be able to educate you on methods of fixing them.
You know when you see people on Instagram who make strength training look ridiculously easy? Yeah, you're not gonna see that here because 1- I have TERRRRRRIBLE BALANCE and 2- because this shit is HARD. 💪🏽🙅🏽💪🏽🙅🏽💪🏽🙅🏽💪🏽🙅🏽 Keeping injuries away with @finishlinept! 💪🏽 BQ OR BUST!!!! #RunSelfieRepeat #FinishLinePT
With marathon season coming to an end I think the biggest and most important thing to stress as a physical therapist who sees these types of injuries every day is that while rest after a race helps decrease pain, and is definitely needed, it doesn't truly solve the problems. Many people go weeks without running thinking that their pain will resolve on its own and find their pain to come right back as soon as they hit the roads or track again. So not only is it important to utilize the offseason to take care of any nagging injuries that still may be troubling runners, but it's also important to take the time to figure out where some weaknesses may be and how they are affecting your form. Too many runners come in weeks before a race freaking out that they started to have pain somewhere and won't be able to finish the race. Take care of some of these issues before the pain causes you to need to take serious time off running. A thorough gait analysis and strengthening program can ultimately lead to improved running economy and efficiency, helping runners continue to set new PRs without getting injured.
Peters J, Tyson N. Proximal exercises are effective at treating patellofemoral pain syndrome: a systematic review. The International Journal of Sports Physical Therapy. 2013; 8(5): 689-700.
Clark N, Bourque R, Schilling J. Treatment of patellofemoral pain syndrome in a track athlete. Human Kinetics. 2014; 19(1): 27-31.
Van der Worp M, Horst N, Wijer A, Backx F, Nijhuis-van der Sanden M. Iliotibial band syndrome in runners: a systematic review. Sports Med. 2012; 42(11): 969-992.
Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment. Sports Med. 2005; 35 (5): 451-459.
If you have the resources available to you to get into Physical Therapy, get into PT. It doesn't matter if you don't consider yourself a serious runner, it will save you so much grief down the line. And if you can't get into PT, go follow Finish Line Physical Therapy on Instagram and incorporate the exercises they share on their channel!
Until next time, #RunSelfieRepeat.