Knee pain is one of the most common problems encountered by runners and cyclists. Initially, most people, quite reasonably, are concerned they have injured themselves, tearing the infamous ACL (anterior cruciate ligament) or MCL (medial collateral ligament). Frequently, however, knee pain (particularly in runners and cyclists) is the result of long established imbalances between certain muscle groups. With these imbalances altering the mechanics of the lower limb, abnormal stresses are placed on the tissues. If the body is then asked to work harder than it is used to, inflammation and pain can result. Often, this pain can be surprisingly severe, leading one to wonder whether something serious is going on. Nonetheless, treatment to restore normal function to the limb, followed by therapeutic exercise, can bring quick resolution. Non-surgical knee pain revolves around three structures. Two are muscles, a portion of the quadriceps (big muscles on the front of the thigh) called the vastus medialis (highlighted in red), and a little muscle the size of a finger, called popliteus, which runs across the back of the knee. The third structure is a broad sheet of connective tissue running from the hip to the knee, called the iliotibial band, or ITB (outlined in blue below). As a result of sitting most of the time, the ITB tends to shorten, and the vastus medialis tends to shut off. Together, this muscle imbalance alters the function of popliteus, whose job is unlocking the knee after each step.Changes in these three structures can have a couple of effects. First, in a repetitive activity like running or cycling, the now-tight ITB can become inflamed by friction. This is usually labeled an iliotibial band syndrome. Second, the kneecap may begin to track towards the outside of the knee, irritating the underlying cartilage. This is usually labeled a patellofemoral pain syndrome (PFPS). In many cases, I have seen this manifest as a severe pain directly behind the knee that comes about a mile into a run. Third, both problems can be present (and usually are). What's worse is that I have frequently seen these muscular imbalances injure the dreaded medial meniscus and medial collateral ligament (the MCL) by forcing them to work harder than they were designed for.
So if you have these problems, what can you do about it? You may think you can stretch your way out of it; unfortunately, the muscle imbalances usually throw off the mechanics of the joints in the low back, pelvis, and leg. This makes other muscles stretch before the ITB. Furthermore, it is very difficult to effectively target the tight muscles with stretching, because as they shorten, the fibers become glued together, in what are know as fascial adhesions. These days, many people try using a foam roller. While I have found them to be quite useful for patients as part of therapy, or to prevent these problem in the first, rolling is usually too painful, and not targeted enough to break up the adhesions.
The best treatment for this is known as Active Release Technique (ART). ART is a soft tissue diagnosis and treatment system which breaks up the adhesions by having the patient actively lengthen the muscle, while the practitioner uses their hands to trap the muscle in a shortened position. While some patients may experience discomfort, the process also reinforces normal movement patterns, neurologically re-educating the patient. With the ITB syndrome, the practitioner may decide to use ultrasound before ART treatment. Ultrasound uses high frequency sound to soften the adhesions, allowing them to release with less pain to the patient, and less effort for the practitioner. Finally, chiropractic adjustments are applied to the pelvis, leg, or low back, allowing the joints move freely within their normal range of motion. This last piece is often under-rated, but proper joint movement is how the brain chooses which muscles to recruit. If joints are disfunctional, then any exercise merely piles conditioning on top of dysfunction.
The hard fact is that the ITB needs to be rolled, and other muscles need to be stretched regularly to maintain the body for repetitive movements such as running and cycling. If all this is done correctly, and you have learned how to avoid the problem in the future, you can expect complete resolution.
