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Marathon Training Injuries Pt II

Lateral knee pain (Ilio-Tibial Band Pain)

You’ve been training for the marathon, you’ve just upped your mileage with your long run being the target and you start to get a pain on the outside of the knee which refers around to the front, below the knee cap. You may have developed what is commonly known as Ilio-Tibial Band Syndrome. This can seriously disrupt your training and can, if ignored, cause you to stop running completely until it has recovered.

What is this?

The Ilio-tibial band is a strip of connective tissue running from the top of the outside of the thigh, connected to the muscles of your bottom, down to connect to the the outside of the knee at the top of the shin. In short it connects your hip to your knee.

The role of the band is to provide stabilisation to the pelvis and the knee.


There are two schools of thought;

  1. With the repetitive nature of the knee bending and straightening the band moves over this bony prominence, called the lateral epicondyle. This leads to localised inflammation of a fluid filled sac called a bursa whose purpose is to guard against friction between structures. However there is little good quality evidence to support this theory of ‘slippage’.

  2. Impingement; this theory states that the band does not move across the lateral epicondyle so friction-related inflammation cannot occur. Instead it is now thought that the condition is related to compression of local innervated fatty tissue. This occurs at 30 degrees of knee bend (flexion) when the foot lands on the ground and into the early stage of the stance phase. During this phase of the running gait, the glutei muscles at the hip contract causing the leg to slow down, generating compression in the band. Scans have indicated that it is usually a fat pad and the bursa tissue between the band and the thigh bone that show signs of injury rather than the band itself, though the band at the knee can be significantly tighter on the affected side as it crosses the knee.

Likely mechanisms for the problem

  1. Muscle weakness or tension, particularly the ones that abduct your leg or lift it out to the side, namely the gluteus medius. This will cause your hip to rotate in and your knee to adduct. Strengthening these muscles can help reduce the rotate and delay the fatigue that will lead to the rotation and thus reduce the compression of the band on the outside of the knee.

  2. Running style: A lot of runnings heel strike/land with their foot infant of them. This leads more time being spent on the foot, with a subsequent increased knee flexion and hip flexion. The result of this ‘sinking’ is an overload of muscle leading to the outward ‘collapse’ of the hip and subsequent inward ‘collapse’ of the knee. These two movements lead to twisting and overloading of the soft tissues and injury.


An osteopath should take a detailed case history including details of your training programme. Details of the pain may include

  1. sharp pain on the outside of the affected knee

  2. Pain referring up to the outer side of the thigh or calf muscle

  3. Increased pain walking downstairs or downhill

  4. Maybe some swelling on the outer part of the knee

  5. Tenderness to the outside of the knee

  6. Maybe some ‘crepitus’er grinding when the knee is bent.

They will observe you walking, squatting and probably also lungeing to identify the way the knee reactions to the loading. They will palpate the leg from the gluts to the knee and there are a couple of special tests that can be performed that will reveal relevant weakness and tension. They will also look at the way your foot and ankle function to identify any thing that may be causes issue from below.

Should you run with ITBS?

This is a difficult question and the mistake is to get back into it too early. It can take 4-12 weeks to recover and sometimes longer. This is dependent on the the active participation of the runner in the recovery process. It is a difficult problem since it can flare up in the middle of a run to the point where you end up having towels the rest of the way. Not much fun if you are in the middle of a long run. So continuing your running may be detrimental to the healing process. If you only have mild symptoms and can run then reducing the column but continuing may be possible.

What should you do?

Whilst nothing able to run you can still continue to do some training as long as they are not aggravating. The ideal is non-weightbearing activities like swimming or cycling, maybe running in a pool or using a floatation device and ‘run’ in the deep end of the pool without touching the bottom.

If you are able to take anti-inflammatories then these may help but always read the instructions and be aware of abdominal issues.

There is a therapy called Radial Shockwave Therapy which can help with the healing process and research on its effects are generally quite positive.

Soft tissue work on tight muscles as wells stretching and strengthening muscle associated with the problem are worth considering, again starting with non-weight-bearing.. These include control of the muscles of the hips, namely external rotators, the abductors, the adductors and the extensors (gluts).

If you do not have gym membership then the use of resistance bands is just as effective and cheap too. The osteopath treating you should be able to demonstrate the exercises you need to do and explain frequency as well as intensity.

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