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Hi Everyone
Wow, I'm not sure what happened to September but it seems that newsletter time has come around very quickly again! Fresh from working on the Wild Run in the Transkei in early September, I thought it apt that the feature of this month's newsletter be running injuries.
For those running junkies out there looking for a new challenge, the Wild Run's 112kms solo running over three days along pristine Wild coast coastline provides an absolutely unique experience. The itinerary is as follows:
Day 1: 43km Kei River Mouth to Kob Inn
Day 2: 35km Kob Inn to The Haven
Day 3: 34km The Haven to The Hole-in-the-Wall
Myself and two other physiotherapists braved the rough Transkei roads to follow the race and pick up the pieces of the competitors' sore legs each day, patch them up and send them on their way. Despite punctures, getting lost (mental note 1- don't use a GPS in the Transkei unless you have uploaded the Transkei software...), working until 10pm, and then finally breaking down in our long suffering Toyota Yaris (mental note 2: only travel in 4x4s on transkei roads!), it was still an amazing experience, which I enjoyed more than any other race I have worked on.
One towed car (first by Bob Skinstad and then by the AA...), three african taxis, a night in Umtata, one missed flight, a hired car and one speeding fine later, I finally arrived back in Cape Town a day later than planned, with sore hands but feeling inspired by the beautiful scenery, the camaraderie of the event and by how much we had helped the runners.
Read on for how to recognise and treat the common running ailments of Iliotibial Band Syndrome and Patellofemoral Pain Syndrome.
Enjoy and take care until next time!
Definition and Cause
ITBS is one of the leading causes of lateral knee pain in runners (although it does occur in other sports as well), and most often presents as a non-traumatic overuse injury.
The iliotibial band (ITB) is a superficial thickening of tissue on the outside of the thigh, extending from the outside of the pelvis, over the hip and knee, and inserting just below the knee. The band is crucial to stabilizing the knee during running, and the syndrome is traditionally thought to be caused by excessive rubbing of the distal portion of the ITB over a bump on the thigh bone, the lateral femoral epicondyle (LFE), with repeated knee movements, leading to inflammation and a failed healing response of the underlying tissue.
More recent studies however suggest that the ITB is firmly anchored to the LFE, and the pain may not be related so much to friction as to compression of a layer of highly innervated fat between the ITB and LFE. This ‘impingement zone’ occurs at about 30° of knee bend as the foot strikes and weight is taken through the leg, during which period the gluteal muscles should contract to decelerate the leg.
This has highlighted the importance of hip musculature strength in the syndrome and anecdotally, I find this to be the single most important factor in treating ITBS successfully. You can stretch until you are blue in the face, but if you don't correct the weaknesses in the hip/pelvis (and if necessary the knee and ankle) that are leading to the altered biomechanics, your recovery may not be successful.
Contributing factors
External factors:
  • -Abrupt increase in running distance or frequency
  • -Excessive downhill and long distance running
  • -Poor running technique
  • -Running on sloped/cambered surfaces
  • -Inappropriate footwear or worn shoes
Internal factors:
  • -Excessively tight ITB and/or other muscle tightness (particularly gluteus maximus, tensor fascia lata, lateral quadriceps/hamstrings)
  • -Muscle weakness (especially the gluteal muscles, but the whole leg can be affected)
  • -Abnormal biomechanics e.g. bow legs
  • -Excessive pronation (i.e. flat feet)
  • -Poor pelvic and core stability
  • -Muscle strength imbalances, often resulting from previous injuries
  • -Tightness in specific joints (hip, knee or ankle)
Signs and Symptoms
  • -Pain is localised to the outside of the knee and can be dull or sharp in nature, depending on the severity
  • -In more severe cases swelling may be present, and the pain may cause -locking or giving way of the knee, as well as limping
  • -Pain is typically experienced during activities that bend or straighten the knee particularly whilst weight bearing
  • -Pain may be worse first thing in the morning or following activity
  • -Aggravating activities include walking and running, especially down hill and down stairs, but also up hill and up stairs
A thorough physiotherapy examination is usually sufficient to diagnose ITBS, but investigations such as an ultrasound or MRI may be used to assist with diagnosis.
Physiotherapy treatment
  • -Advice on activity modification. Sufficient REST is vital in the early stages
  • -Ice, anti-inflammatories and electrotherapy for pain relief
  • -Soft tissue massage
  • -Dry needling
  • -Taping (especially when rest is not possible, like on the Wild Run!)
  • -Specific stretching of tight muscles
  • -Progressive strengthening exercises, specifically of the gluteal and pelvic muscles, but also of the knee, ankle and foot muscles as necessary
  • -Balance retraining
  • -Biomechanical corrections
  • -Footwear advice
  • -Slow return to running
There is good evidence to show that conservative treatment works well, provided the causative factors are identified, and the correct exercises prescribed, progressed and followed through on. Other treatment options include cortisone injections and surgery as a last resort. Recovery can take up to 6 weeks, as the muscles need time to strengthen, but running can be resumed during this time, with emphasis on slow, progressive mileage increase. If not treated properly or rested sufficiently, ITBS is one of those injuries that can reoccur or persist for a long time, so consult your physiotherapist sooner rather than later!
Patellofemoral pain syndrome (PFPS) is the term given to pain originating from the patellofemoral joint (i.e. the joint between the knee cap (patella) and thigh bone (femur). Patellofemoral pain syndrome is usually associated with inflammation or damage to structures of the patellofemoral joint.
While the exact cause of patellofemoral pain isn't known, it's believed that the way the patella tracks along the groove of the femur can lead to irritation of the cartilage on the underside of the patella. The patella can move up and down, side to side in the groove, as well as tilt and rotate. Normally, the patella is aligned in the middle of the patellofemoral joint so that forces applied to the knee cap during activity are evenly distributed. In patients with PFPS, the patella is usually misaligned relative to the femur, which therefore places more stress through the patellofemoral joint and can result in pain and inflammation.
The cause of this misalignment is multifactorial and includes overuse and overload theories, as well as biomechanical and muscular imbalance theories. Of particular note in the latter category, is the weakness of hip joint musculature, leading to altered biomechanics, as well as imbalance between the inside and outside thigh muscles: vastus medialus oblique (VMO), the inner thigh muscle, responsible for medial tracking of the patella, is often weak relative to the tighter, stronger outer vastus lateralis.
Contributing factors
  • -Excessive or inappropriate training or activity, leading to overuse or overload
  • -Inappropriate footwear or training surfaces
  • -Poor training technique
  • -Muscle weakness (especially the VMO and gluteal muscles)
  • -Tightness in specific joints (hip, knee or ankle)
  • -Tightness in specific muscles (especially the ITB or quadriceps)
  • -Muscle strength imbalances, often due to previous injury
  • -Poor lower limb biomechanics
  • -Poor pelvic/core stability
  • -Poor foot posture: excessive pronation/supination
  • -High placed patellae or a shallow groove
Signs and Symptoms
  • -Pain at the front of the knee and around or under the knee cap, sometimes at the back of the knee or on the inner or outer aspects
  • -Often felt as a vague ache that may increase to a sharper pain with activity
  • -Pain is typically experienced during activities that bend or straighten the knee particularly whilst weight bearing
  • -Aggravating activities include going up and down stairs or hills, squatting, running or jumping, as well pain whilst sitting with the knee bent for prolonged periods.
  • -There maybe an associated clicking or grinding sound when bending or straightening the knee, and possibly giving way or collapsing of the knee due to pain
  • -In more severe or chronic cases, quadriceps muscle wasting is evident
A thorough physiotherapy examination is usually sufficient to diagnose patellofemoral pain syndrome, but investigations such as an X-ray or MRI may be used to assist with diagnosis.
Physiotherapy Treatment
Most cases of patellofemoral pain syndrome settle well with an appropriate physiotherapy programme. Treatment involves:
  • -Advice on activity modification- REST from aggravating activities may be necessary
  • -Ice, anti inflammatories, compression and electrotherapy for pain relief in the acute stage
  • -Soft tissue massage to release tight muscles
  • -Taping or bracing to correct patella position
  • -Mobilization of the patella or any other stiff joints e.g. hip/ankle
  • -Dry needling
  • -Stretching of relevant tight muscles
  • -Progressive exercises to improve flexibility, balance and strength (especially the VMO and gluteal muscles)
  • -Biomechanical correction
  • -Referral for orthotics if necessary
In the majority of cases conservative management is very successful, provided the correct causative factors are identified and the exercise programme is progressed and followed through properly. Surgery should be a last resort and is only recommended in specific cases. Recovery may take anything from 1-3 months so once again, consult your physiotherapist sooner rather than later!
With a holistic approach and more than ten years' experience, Andrea strives to identify the source of clients' symptoms and return them to full health and pain-free function, whether in everyday life or on a competitive sporting level. Offering thorough assessments and a hands-on approach, she treats all general physiotherapy conditions involving muscle, joint and neural problems, ranging from back and neck pain to post-operative orthopaedic conditions. Her special interest in sports injuries and rehabilitation is complemented by her certification as a pilates instructor.


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