Sports Injuries

El Paso, TX. Chiropractor, Dr. Jimenez takes a look at top running shoes that are great for knee pain and Iliotibial (IT) Band Syndrome.

Running Shoes: Knee pain is one of the common problems with most active people. It could get worse for those who love running, especially the athletes. A majority of them suffer from knee pains each year. This pain hinders you from enjoying your daily sports activities and might even become worse with time if not treated correctly. There are causes and cures for such pains that this article is going to look at, but the main focus is on the best shoes for knee pain, also referred to as Iliotibial (IT) Band Syndrome.

This can happen due to various causes like overtraining, running many hills, and wrong running form, among others. These injuries are very frustrating as they can take up to months to go away. This is the reason different companies have designed shoes that will offer you support for any knee problem.

What Goes Wrong

The iliotibial band (ITB) is usually a structure whose job is to provide leg stability whenever you take a step. It works with the hip muscles in a thigh's outward movement and also helps counter the movements within the knee joint. This band starts in the hip and ends just under the knee joint.

Repeated use of the ITB leads to stress, causing knee pain. You will also notice clicking sensations from the joint as ITB snaps across it. This pain is always experienced when the heel comes into contact with the ground; running slowly or downhill tends to make the symptoms worse.

ITBS will usually start as tightness while running but continues to a point where the pain is severe and unbearable. Although ITB continues to tighten when overstressed or injured from training, this is not the main problem. What causes the injury is how the ITB functions and the weakness around it.

The ITB is generally a weak structure and any weakness around it will lead to injury. Most runners have weak core muscles due to the fact that they don't do strength training or have never been in any sports with side-to-side movement.

Signs Of IT Band Syndrome

If you are a runner, you will be able to distinguish ITBS by:

• A swelling
• A cracking feeling when stretching the knee
• A feeling of burning, stinging and aching on the outer side of the knee that might migrate to the thigh. You will notice these discomforts especially, on your second half of the run.
• Bending the knee at 45 degrees causes severe external knee pain

Criteria You Should Follow When Selecting The Best Running Shoes for ITBS

​There are various things that you should always consider when buying running shoes. Since most runners experience knee pain, it is wise to look for shoes that will help alleviate this pain without slowing them down. Below are some of the features to look out for in running shoes:

Stability/ Support

Since it is common to have knee pains due to lack of motion control and lack of stability, it is good to choose shoes that will offer you the support you need while running. If your running shoes don't have any stability, you will end up stressing out your knee, which will result in pain and discomfort while running.

Fit

If you want to do away with pain, you might consider looking for a fit pair of shoes as they will reduce any pain, causing issues in the long run. Pay attention to small specifics like shoes that offer enough heel space, sufficient toe box room, and enough space for wide feet. Your toes should be able to move freely without being constricted.

If your foot cannot move freely and the toes are restricted from spreading, it could lead to painful issues in your feet, legs, and knees.

Motion control footwear is not the whole solution; you need to ensure your feet can still function naturally as they are supposed to.

Comfort

No one wants to wear uncomfortable shoes! Each of these selected best shoes come with upper and underfoot comforts to ensure you get to enjoy your run.

Most of these shoes are made with DNA technology, Gel cushioning, and REVlite midsole for ultimate comfort.

Durability

Your running shoes should run their course without falling apart as this will cause you pain in the long-run. If they promise to offer you support, they should do just that and not start peeling off and tearing when you are on the run.

Breathability

Although this has nothing to do with knees, it is paramount that your running shoes have enough breathing space to avoid accumulating excess moisture, which might bring discomfort and other feet related problems.

There is no magical cure for knee pain and you should always know the root cause. This way, you will be able to come up with the best solution of minimizing or even eliminating the pain entirely. Although there are various causes of knee pain, this article is focusing on ITB syndrome which happens to be one of the causes.

The ​​below 5 shoes have passed the durability test to ensure they give you maximum performance.

Reviews Of The Top 5 Shoes

These shoes have been selected with the runner's welfare in mind. They will help deal with the ITBS, which is a problem for most of them. Since one way of dealing with this condition is getting good running shoes, here is a review of such products.

Asics Gel Kayano 23

This upgraded version is lightweight to help with any knee problems. It offers you comfort through cushioning that help absorb shock as you run as well as other features like grip, fit, and durability. The shoe has an added outer sole to ensure it lasts you as long as possible.

PROS

• ​Gel cushioning will act as a shock absorber for more comfort
• ​Has superb breathability feature
• ​Is ideal for overpronation and knee pain
• ​The outsole's traction will offer the intended support on various surfaces

CONS

• ​It is a bit pricey

New Balance 890v5

It tops the list of 5 best running shoes. Also, it has remained the first choice for most runners with knee pain issues. This pair offers all the above functionalities too, making it your best choice.

PROS

• ​It comes with one of a kind breathability and fit due to its great FantomFit design
• ​Its smooth upper construction will ensure no irritation occurs
• ​The REVlite midsole will give you much needed cushioning

CONS

• ​It has a narrow toe box and might not fit a person with a wide foot

​Puma Faas 600 V3

Puma models have never disappointed, and this one is no exception. Puma Faas 600 is the solution to your knee pain. It is also an affordable option for the short-handed.

PROS

• ​Great breathability
• ​Comes at a reasonable price
• ​It's lacing system and fit offers you a secure and comfortable run
• ​It is designed to fit perfectly

CONS

• ​There have been reported concerns about the outsole's durability

New Balance 1080v7

This is another great choice on the list. It is one of the New Balance Fresh Foam Series. Its midsole offers you the required support coupled with comfort to eliminate knee pains.

PROS

• ​Very durable
• ​Enough breathability for long runs
• ​Good amount of cushioning and support from the Fresh Foam midsole
• ​It fits like a sock giving you a confident use

CONS

• ​The upper design is not seamless
• ​Can be stiff

Saucony Hurricane 16

This is the 16th edition of the Saucony Hurricane, which offers a combination of steadiness and protection. Those with knee pain have agreed with the stability offered by this shoe. It is also cushioned to help you go for long runs without any pain or injury. It is perfect for heavy runners and those who are out of shape due to inactivity.

PROS

• ​Superb stability
• ​Lightweight rubber offers protection and cushioning
• ​Great ground contact
• ​Reflective parts allow you to have a safe run
• ​Comes with Sauc-Fit Technology that enhances its comfortability

CONS

• ​It is a bit narrow
• ​Limited colors to choose from
• ​Might be heavy for fast runners

If you are a long-distance runner, it is good to know that your shoes cushioning will wear out quite easily and you might be tempted to continue using them since they look good on the outside. This is a big mistake. The following will help you prevent any more ITBS recurrences:

• Replace running shoes frequently to avoid wearing those with worn out inner cushioning
• Always give your shoes time to rest so that the cushioning can get restored; it would be wise to have two pairs of running shoes.

Although shoes can offer you relief from ITBS, it is better to look out for other ways of helping you cope with or eliminate the pain entirely. Also, know what triggers the problem and avoid it at all costs.

These shoes have been tried and tested and found to offer support and help in managing the iliotibial band syndrome. Asics takes the lead on these best shoes. It comes with gel cushioning that will offer you the best shock absorption and maximum comfort as seen above. Its sole is also made to help you tackle any terrain and you can be assured that your knees will thank you later. The only drawback is the price, which is on the upper-side. However, always remember that cheap is expensive.

If you are an active person or an athlete suffering from ITBS, go ahead and get yourself a pair of these shoes as per your preference and choice.

in running

Hey there, I'm Zoey, founder and the main editor of The Babble Out. I know nobody's life is smooth as they wish, and it’s the same with mine. I had some terrible news a few years ago and running was the way I got through these issues. This has given me enough motivation to create this blog, so that I can give you a helping hand for as many daily problems as I can. If you are curious why "babble out" is the​ name of the blog, then check the "About" page and find out more about me.

Chiropractor, Dr. Alexander Jimenez looks at the way this common injury shows itself.

Introduction

Iliotibial band syndrome (ITBS) between the knee is frequently diagnosed in sport injury clinics. ITBS presents having an incidence rate of around 22% in most lower extremity running-related injuries (1) also has been said to be the second most common complaint amongst distance runners (2). ITBS has been given the expression 'runner's knee'.

Trainers like endurance runners who perform flexion and extension combined with loading are subjected to this illness. ITBS presents during the first two or three miles in running with no mechanism of injury, which can make identifying the cause more interesting. With plenty of factors having been considered within the literature, changes are often purported to be a cause of ITBS. But some biomechanical factors have been researched and have been found to have little or no effect in the start of ITBS. Therefore this text's point would be to examine the biomechanical changes which may induce an individual to the beginning of ITBS. The research published reviewed is largely based on a current systematic review that was published in Physical Therapy in Sport in 2014 (3).

Anatomy & Function

The iliotibial band (ITB) encapsulates the tensor fascia latae (TFL) presenting with both deep and superficial fibre attachments at the pelvis (4). In addition to attaching to the TFL, approximately three-quarters of the gluteus maximus tendon also conjoins with the ITB (4). The ITB courses along the lateral aspect of the hip and passes the greater trochanter. The ITB maintains an attachment on the posterior ridge of the femur whilst attaching itself to the fascia. The ITB has a fixed attachment at the lateral femoral condyle where it then divides into three segments with the first being the lateral patella (3). The remaining two segments cross the knee joint to insert at the head of fibula and most distally at the infrapatellar tubercle also known as Gerdy's tubercle on the tibia (3). Figure 1 illustrates the location of the ITB.

The ITB passively functions to resist hip adduction, hip internal rotation and internal rotation of the knee in accordance with its attachments at the pelvis, femur and tibia(3). The gluteus maximus functions, through its attachment, to increase stability through the hip and knee complex by increasing the tension of the ITB(4). It is possible to see, based on its attachments at both the knee and hip, how changes could bring about the onset of ITBS.

Studies have proposed that as the knee flexes and extends the ITB 'slides or flicks' over the lateral femoral condyle of the knee causing an irritation beneath. This notion was debated by Falvey and colleagues (5), who stated that it was highly unlikely that the ITB would flick or slide over the bone during knee flexion due to it not being a loose structure. But the authors did agree that the impact of compression on the richly innervated fat pad was pain's cause but by strain of the ITB where pain presents crossing the lateral femoral condyle. Strain rate and strain magnitude were measured in a prospective study involving female runners (6). The results indicated that frequency of strain of the ITB at the lateral femoral condyle was greater that the strain magnitude. This implies that a runner might have the ability to run for a short period but then incur lateral knee pain because of the strain to the ITB.

MRI scans have ascertained the knee flexion angle of 30° elicited the greatest compression of the ITB at the point of heel strike, whereas others have said that maximal compression occurs between 20-30°(2,6). A knee flexion angle at the point of heel strike has been found to be significantly different with 20.6° in ITBS patients compared to 15.3° in the control(7). Downhill running produces a greater knee flexion angle at the point of heel strike eliciting a larger strain load to the ITB and therefore this is often a main precursor to ITBS (6). Although an elevated knee flexion angle at the point of heel strike has been considered to contribute to ITBS, it is essential to examine the lower extremity from the frontal and transverse planes too and not solely from the sagittal plane (2).

Rearfoot Eversion

It's possible to envisage how rear foot eversion could contribute to ITBS causing internal rotation of the tibia resulting at the distal attachment in greater strain of the ITB. In contrast Ferber and colleagues (2) indicated that there was no significant difference in the peak eversion angle of the female subjects, who were previously diagnosed with ITBS but were now symptom free, compared to controls. In a similar study non-significant differences were found between the currently symptomatic ITBS patients and controls for rear foot eversion (8).

Louw & Deary(3) found that ITBS patients sometimes demonstrated decreased eversion angles, accompanied by decreased internal rotation of the knee, at the point of heel strike. Ferber and colleagues (2) noted an increased inversion moment in the ITBS group which was suggested to control and limit the eversion moment. By comparison, currently symptomatic ITBS patients demonstrated a substantial difference compared to a control group with twice the rear foot motion during running (9).

Knee Internal Rotation

Peak internal rotation angle of the knee was found to be significantly greater in the ITBS patients when compared with controls at the point of heel strike (2). This research was supported by other studies who also found a significant effect for increased internal rotation of the knee following a run of moderate intensity to physical exhaustion(7). With excessive rotation comes compression due to increased strain of the ITB at the attachment.

An explanation of increased internal rotation of the knee was attributed to excessive external rotation of the femur perhaps due to shortening of the piriformis, gemellus inferior and superior and the obutrator externus (8). The authors added that excessive rotation at the hip might result from muscular activity of the rotators that were hip being the medius, minimus and the tensor fascia latae. These studies(2,7) were retrospective in design in that they tested healthy runners with a history of ITB pain, whereas(8) was a prospective study of patients with ITBS at the point of testing.

Hip Adduction Angle & Hip Abductor Strength

The hip adduction angle during the stance phase has been suggested to be greater. Ferber and colleagues(2) found that the peak hip adduction angle was significantly greater in the ITBS cohort and stated that with 95% confidence. Increased angle results in increased stress to the ITB and consequently increased compression at the lateral femoral condyle when combined with increased internal rotation of the tibia.

Figure 2 illustrates, when peak hip adduction and internal rotation combine, how this may result in increased the compression of the ITB at the lateral femoral condyle. Louw and Deary(3), however, stated that it remained inconclusive whether the peak hip adduction angle was a substantial element. Additional research is therefore required to support Ferber and colleagues'(2) initial findings as this study was a retrospective study carried out on healthy female runners with a history of ITBS.

Hip Abductor Strength

It's been proposed that an increased peak hip adduction angle may coincide with hip abductor activity involving the gluteus medius in this group. During the stance phase of gait the gluteus medius functions to keep stability. Research has indicated that during stance the adduction forces can exceed three times an individual's body weight(3). What's more, it was stated that these forces were beyond the metabolic capacity of the gluteus medius to main pelvic stability during the stance phase using just this muscle alone(3).

Louw and Deary (3) were not able to identify a heightened hip abductor moment in the ITBS patients with increased peak hip adductor angles and suggested that it was more of an issue of timing as opposed to the size of the hip abductors. Louw and Deary (3) stated that the research is yet to examine trunk and pelvic movements in ITBS patients and it is plausible to suggest that biomechanical changes from higher up the kinetic chain has the potential to be a contributing element in ITBS etiology.

A research study of 24 (14 female, 10 male) patients with ITBS undertook a six-week rehabilitation programme to increase the strength of the hip abductors(10). Following six weeks of hip abductor strengthening to running 22 patients reported being pain-free and had returned. The female patients reported an average hip abductor torque increase of 34.9% and the male patients found 51.4% increase. However this study used a hand held dynamometer to measure isometric strength and therefore Fedricson (10) findings should be viewed with caution.

A more recent study assessed the hip abductor strength of currently symptomatic patients with healthy controls in a fixed position(11). The results indicated that no substantial differences occurred for static and dynamic hip abductor strength between the groups. Further research should look into the EMG and strength of the hip abductors in the role of managing ITBS. Table 1 shows of significance in the some of the variables of the studies used in this text.

Rehabilitation programs, following periods of immobilization and during, should include gluteal exercises to provide stability to the leg that is involved. If active exercises for the gluteal muscles are provided in a manner that is secure and effective then this can influence the period of transition from non weight. It's prudent based on the research provided to date to develop function although research is lacking in terms of quality and volume as to the biomechanical influences on the etiology of ITBS. This guarantees that once load bearing commences that the leg that is involved has the stability and control that is active to keep the beginning of load of the ITB.

Summary

The recent review published by Louw and Deary(3) indicates that much of the research published within the literature depending on the etiology of ITBS is inconclusive. The level of research is relatively low and is based on retrospective trials. The research does indicate that knee biomechanics and abnormal hip is involved in the occurrence of ITBS. The authors ascertain that muscle strength is involved as is foot biomechanics that are abnormal. It is recommended that future research should measure kinematic movements of the hip and knee during downhill running as this is a complaint of ITBS onset.

References
1.Clini J of Sports Med, May 2006,16, (3), 261-268
2.J of Sports Phys Therap, Feb, 2010, 40, 2, 52-58.
3.Phys Therap in Sport, 2014, 15, 64 e75.
4.Surgic and Radiologic Anatomy (Dec) 2004; 26, (6), 433 - 446
5.Scand J of Med & Sci in Sports, Aug 2010, 20 (4), 580-587.
6.Clini Biomech, 2008, 23, 1018-1025.
7.Gait Posture. 2007 Sep, 26 (3), 407-13
8.Clini Biomech, Nov 2007, 22 (9), 951-956.
9.Med Sci in Sport & Ex, 1995, 27, 951-960.
10.Clini J of Sports Med, 2000, 10:169–175.
11. Int J of Sports Med, Jul, 2008, 29 (7), 579-583.

El Paso, TX. Chiropractor, Dr. Alexander Jimenez asks if this overuse injury is wrongly named...

Lateral knee pain is a common event in runners as well as conducting popularity increasing it's anticipated so too will the variety of running related injuries. ITB friction syndrome (ITBFS) is a non-traumatic overuse injury and is the most common cause of lateral knee pain in runners and cyclists. Despite its common occurrence, there is limited research into the etiology and treatment of this illness. ITBFS was initially thought to be due to repeated flexion and extension of the knee resulting in friction of a bursa from the over- lying ITB. More recently, but the pathophysiology of the condition was debated. It is currently thought to be caused by compression of the underlying connective tissues instead of extending and extending bursitis. This article will outline the current thoughts on ITBFS such as the anatomy, pathophysiology, diagnosis and the evidence of some treatment options.

Anatomy

The ITB is your broad fibrous ring that creates the lateral portion of the tensor facia latae and it totally envelops the thigh like a stocking(5). It is thought of as thickening of the circumferential fascia rather than a different structure(1).Proximally the tensor fasciae latae and the majority of the tendon of the gluteus maximus insert on the ITB1, which then runs distally down to the lateral condyle of the tibia and beyond that it is interwoven with the crural fascia. In the knee that the ITB includes a three-bone attachment sites: the tibia, the femur and the patella (see Figure 1).

The ITB is attached into the distal femur by fibrous strands(4),which move by the ITB via the periosteum into the bone. It was originally believed that these bands were pathological but since they've been discovered to be constantly present it implies that they aren't correlated with pathology but instead they're a typical anatomical feature(5).

Pathophysiology

The exact pathogenesis of ITBFS is still controversial. Originally it was considered to be due to excess friction of the ITB on the medial femoral epicondyle, which created inflammation of this ITB or under- bending bursa(7). Histopathology studies in runners with ITBFS demonstrate chronic inflammation, hyperplasia, fibrosis and mucoid degeneration of the lateral femoral recess. The presence of a bursa, however, has been debated and Falvey (2010) failed to find a single bursa between the ITB and the lateral lateral femur in the dissection of 20 cadavers(6). On account of the absence of a bursa they proposed that this highly vascularized connective tissue would be the pain-producing arrangement in ITBFS(5).

Furthermore, to make friction, the ITB needs to be able to slide over the lateral femoral epicondyle through knee flexion. They proposed that due to this ITB's inability to slide over the lateral epicondyle the neighborhood inflammation seen on MRI is therefore more likely to be related to compression of this connective tissue rather than any friction(4). Any inflammatory process which occurs during ITBFS may consequently be more likely to be connected with the region of subfascial fat between the ITB and the femur rather than inside a bursa(5).

This compression concept has been further tested by Fairclough (2006) that looked at the position of this ITB during various degrees of knee flexion and extension. Since ITBFS is said to occur at between 30 and 60 degrees of knee flexion they looked at these places and compared them using the position of this ITB in knee extension. On their MRI research they showed that in 30 degrees of knee flexion that the ITB was compacted from the lateral epicondyle of the femur and was "hauled away" at full knee extension. Considering these findings by Fairclough and that no bursa has been found on cadaver dissections, as well as the presence of strong fibrous bands that would stop any lateral movement of this ITB, ITBFS ought to be considered a pathology brought on by compression instead of friction.

Increased compression forces around the lateral epicondyle of the femur are brought on by knee flexion but may be caused by enhanced tibial internal rotation. When the tibia internally rotates, the ITB attachment onto the tibia changes medially, which might lead to compression in the lateral femoral epicondyle. Tibial internal rotation may be caused by a large number of biomechanical factors such as poor gallbladder control, ie enhanced hip add/internal spinning, excessive pronation, genu valgus amongst others(1). Figure 2 demonstrates a runner with a history of ITBFS with significant femoral adduction and internal rotation as well as foot pronation during a single-leg squat. These variables therefore must be addressed and considered when treating an athlete with ITBFS.

Diagnosis

They report an arc of pain during knee flexion in 30-60 degrees. They will often don't have any pain on full knee flexion or extension. They'll be maximally tender within the lateral femoral condyle that is 2-3 cm higher than the lateral joint of the knee (see Figure 3). Ober’s test is often painful and tight and knee flexion in this test position will cause a painful arc between 30 and 60 degrees of knee flexion.

Treatment Options

Treatment of ITBFS ought to be directed at both regional factors to reduce compression and thus pain/inflammation in addition to causative factors. Originally to reduce compression forces at the lateral epicondyle flexing the knee to 30° ought to be avoided and anti inflammatory modalities are encouraged. The scientific evidence for some of the more common treatment choices are summarized below:

Medication

Short duration (less than seven days post- onset), coupled NSAIDS and paracetamol seemingly has a more beneficial effect than both NSAIDs only and placebo medication when looking at pain running on treadmill(two). It's important to note that all groups showed some improvement on this time. From this research it can be concluded that pain relief is also important in the acute phase of ITBFS. Mixed NSAIDs and paracetamol seems to be the best option.

Corticosteroid injection

Guneter and Schwellnus (2004) compared the effects of corticosteroid injection (CSI) and placebo injection (local anesthetic just) at several runners with ITBFS of less than two weeks' duration. Both groups showed improvement over this period with the CSI group considerably better than the control group.

Phonophoresis

Phonophoresis was proven to be effective in comparison with immobilization in subjects who had ITBFS for 2-3 weeks prior to treatment. This study compared time taken to return to operating at 6.5 miles/hour on a treadmill(2).

ITB stretching

Since the ITB is a thick fibrous ring, lengthening of this ITB is likely to be limited. The muscular component of the ITB (TFL and glut max) appears to play an important role in its tension and therefore therapy ought to be aimed at treating these muscular components as opposed to the ITB itself(6).

Transverse Friction Massage

It was concluded that the addition of nearby transverse friction massage didn't alter the therapeutic outcome of physiotherapy from days 0-102. Further study ought to be conducted to deter- mine whether deep tissue massage throughout the proximal attachments of the ITB including TFL and glut max has some beneficial consequences.

Abductor Strengthening

Hip abductor strength has been proven to be significantly less about the injured side in both female and male athletes with ITBFS in contrast to a control group(3). It is important to understand that this could either be the cause or the effect and further research ought to be undertaken to ascertain the effectiveness of hip abductor strengthening programs in those with ITBFS. Due to the compression (and pain) in 30° knee flexed hip abductor strengthening drills ought to steer clear of this position until it becomes symptom-free. Exercises that may be utilized as hip abductor strengthening in the first phases of ITBFS would consist of jet and crab walking with band around foot (see Figures 4 and 5). These exercises avoid knee flexion but still load the hip abductor/ outside rotator muscle bands.

Conclusion

The cause of ITBFS is multifactorial, also as a result of lack of a bursa and the existence of strong fibrous bands, it should be regarded as a compression injury as opposed to a friction injury. An exhaustive biomechanical assessment particularly focusing on variables that could contribute to increased compression of this ITB onto the lateral femoral epicondyle is essential to help identify the cause of ITBFS within an athlete. When the acute phase settles, therapy should be directed towards fixing the biomechanical causes including hip abductor/external rotator strengthening drills and when necessary foot biomechanics must be addressed.

References
1. Brukner P and Khan K (2012) Clinical Sports Medicine 4th edition McGraw Hill
2. Ellis R, Hing W and Reid D (2007) Iliotibial band friction syndrome-A systematic review Manual therapy 200-208
3. Van der Worp et al (2012) Iliotibial Band Syndrome in runners. A systematic review. Sports medicine 42 (11) 969-992
4. Fairclough J et al (2006) The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of Anatomy 208 309-316
5. Fairclough J et al (2007) Is iliotibial band syndrome really a friction syndrome?. Journal of Science and Medicine in Sport 10 74-76
6. Falvey et al (2010) Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scandinavian Journal of Science and Medicine in Sport 20 580-587
7. Van der Worp et al (2012) Iliotibial Band Syndrome in runners. A systematic review. Sports medicine 42 (11) 969-992