Calgary Sports Therapy

The Truth About Lateral Knee Pain

By Dr. Shawna M Pho, BSc(Kin), DC

Many athletes complain of the condition known as “Iliotibial Band Syndrome” or ITBS. The condition often presents as lateral knee pain (pain outside the knee), or also as lateral hip or leg pain. This condition is particularly prevalent among athletes involved in running or cycling activities. Several cyclists experience pain or clicking on the outside of their knee, which often comes on at approximately the same time into their ride or run. Some feel like a knife is being plunged into the outside of their knee, while others experience a constant throbbing pain. Often times, athletes will only feel pain at the knee, and other times, athletes feel only a generalized tightness at the hip.

The iliotibial band (ITB) is a thickened strip of fascia that extends from the top of the hip at the iliac crest, down to the knee where it inserts into a bony prominence on the outside of your knee, known as the lateral tibial tubercle. The ITB also receives part of the insertion of the tensor fascia lata and gluteus maximus muscles, in essence creating its role as a force transmitter from the hip to the knee. When the knee moves through flexion and extension (bending and straightening), such as in running or cycling, the ITB’s position relative to the femur changes. In full extension, the ITB lies in front of the lateral femoral epicondyle (a bony prominence on the outside of your knee, above your knee cap), while at 30 of flexion the ITB lies behind or on top of the lateral femoral epicondyle. It is this position of 30 of knee flexion that is known as the ‘impingement zone’ where the ITB experiences the greatest amount of friction. According to a study in The Knee Journal (Farrell KC, Reisinger KD, Tillman MD. Force and repetition in cycling: possible implications for iliotibial band friction syndrome. The Knee 2003; 10: 103-109.), it is the repetition of the knee constantly passing through the impingement zone during cycling that plays a prominent role in the onset of ITBS. The repetitive friction of the ITB passing over the lateral femoral epicondyle will lead to an initial state of irritation and inflammation, which if left untreated will result in the formation of scar tissue and tissue degeneration.

To date there have been many different approaches to the treatment of ITBS. Some include stretching, massage, ultrasound, and soft-tissue techniques, all with a varying degree of effectiveness. While the treatment will often clear up the patient’s symptoms, there is a large degree of recurrence weeks, months, or years down the road with continued activity.

The most commonly overlooked aspect of the treatment of ITBS is the active strengthening and rehabilitation of the involved structures. Until recently, it was not entirely understood what the precipitating factors were in the development of ITBS. A recent study in the Clinical Journal of Sports Medicine (Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, and Sahrmann S. Hip abductor weakness in distance runners with iliotibial band syndrome. CJSM 2000; Jul 10(3): 169-175.) revealed that runners with iliotibial band syndrome had decreased strength in the muscles that abduct the hip (raise the leg out sideways) when compared to runners without ITBS. These muscles, otherwise known as the gluteus medius and minimus, also play a large role in the stability of the pelvis. Standing on both feet, if you raise your left leg in the air, the right gluteus medius/minimus is responsible for keeping the hip steady so that it doesn't buckle underneath you. You can imagine the implications of a weak or tight gluteus medius when it comes to sporting performance. If these muscles are not working at peak function, then you will see a lot of lateral deviation of the pelvis during activity and power and speed are lost. If the gluteus medius/minimus muscles are weak, nearby muscles attempt to take up the slack. The tensor fascia lata muscle, which acts as a hip flexor and a weak hip abductor, will attempt to accomplish the action of the weakened glutes. Now here is where it gets interesting. The tensor fascia lata (TFL) is directly continous with the iliotibial band (ITB), and any contraction of the TFL transmits itself down the ITB. Because the ITB attaches at the lateral knee at its most distal end, this is why you get lateral knee pain as a result! In essence, knee pain is a result of weakness at the hip! If you understand the mechanism, then you will also understand why treatments aimed solely at the ITB and lateral knee are only temporarily or not at all effective.

This same study that discovered the relative weakness of the hip abductors in persons with ITBS also revealed that after a 6-week rehabilitation program aimed at strengthening the hip abductors, 22 of 24 runners were pain-free, and were able to return to running and did not suffer any recurrence of their symptoms after 6 months. As you can see, active rehabilitation was the key to resolving the issue. While this study was conducted on runners, the results will still hold true for cyclists. The mechanism is the same; weakened hip abductors will place more strain on the TFL which will transmit itself down the ITB. A tightened ITB will result in more friction through the ‘impingement zone’, and thus more pain.

Soft-tissue techniques such as Active Release Techniques and Graston Technique are very effective in treating the symptoms of ITBS. Combine these techniques with a hip rehabilitation program, and not only will your pain resolve, but it will be less likely to return. Be careful when discussing a rehabilitation program with your trainer or health care practitioner. The strengthening of the hip abductors demands a very particular pelvic position in order for the glutes to contract in the absence of the TFL. If the TFL is still trying to compensate for a relative weakness, all you are doing is exacerbating the problem instead of fixing it. Make sure to consult a health care practitioner with a strong knowledge of rehabilitation. Don't let a simple problem side-line you from doing what you love.