My open
relationship with ITBS
Disclaimer: This article is a thoroughly and utterly
detailed personal experience that can be very interesting, or very boring, it’s
all about your perspective.
Hi,
my name is Harith and I've been in an on and off relationship with Iliotibial
band syndrome, a.k.a ITBS, for just over four months as I’m writing these
lines.
But
first let’s back up a bit. I've been running for almost two years now, and my
highlight was completing the Muscat half marathon 2014 in 1:49:02.
During
September 2014, while on a holiday in the UK, I decided to run the Richmond
park 10K race for fun (and for my new love for medals) after months of hard
weight and plyometric training accompanied by not-so-much running mileage to
maximize muscle growth, which was unfortunately minimal.
Long
story short, about three days after the race, I started getting pain on the
outside portion of my left knee. The pain and discomfort was manifested when
the knee was bent about 20-30° going up or down the stairs. I thought I was
just fatigued by the race and the months of training and said it’ll sort itself
out during my rest and recovery period which I was taking next. IT DID NOT.
The
pain reoccurred when I decided to play football after coming back from my
holiday, so I stretched my muscles and decided to rest again for a while. But
the pain continued. That is when I knew that I had to see a physician for some
diagnosis, because I thought I had a semi-torn knee ligament.
I
decided to head over and seek advice from an orthopedic consultant, which
unfortunately was by no means professional enough to address my serious injury.
His test was having me sit kneeling on both knees, and asked me if it hurt. It
didn't. “You’re fine then.. Just rest for two to three weeks and do straight
leg raises (quadriceps sets) in your bed”. He also recommended using a gel for
pain, and wearing knee support which I had already.
I
had already rested a week when I visited him, so it was two weeks to go before
I start my training program for the 2015 Muscat Marathon that I wanted to run.
I waited the dreaded two weeks of boring rest, and went for a test run, but the
pain gradually and eventually came back.
That’s
when I decided to visit a more trust-worthy orthopedic consultant, whom
diagnosis wouldn't be just asking me to kneel down and see if it hurts or not!
So during
November I contacted a close friend of mine who is on the verge of getting his
M.D. and he recommended me going to this one specialized health center which I
did not hesitate to do.
I
had an appointment on the 10th of November in which I briefed the
consultant about my history and told him about my last experience with the
previous consultant. From there he performed a series of tests on my left leg
while having me lying down. It did not take him a long time to find out what’s
wrong. “You have runner’s knee, it’s called ITBS or illotibial band syndrome”
I
was exhilarated by the fact that there was nothing wrong with any of the knee
ligaments, which was my suspicion.
I
asked him about what I should and shouldn't do, and he said I could gradually
go back into running (jogging easy pace to be specific), which was great news
for me.
I
went back home with a big grin and a wide smile on my face. “My knee is fine,
I’m going to run the marathon” was what I told myself.
On
the 16th of November I decided to hit the road for a test run, so I
ran 2.33 kilometers a 7:08 mins/km which was a very short and slow boring run,
or jog to be precise. It didn't hurt and I was over the moon by then.
I
kept running for nine more times until the dreadful lateral pain decided to
come say hello again when I upped my mileage up to 4.8 kilometers by the 8th
of December, which was two days before my follow up appointment 4 weeks after I
came in. I was so bummed because I thought I had overcome the injury and was
ready to up the tempo and even start playing other sports like football again.
My
follow up appointment was not with the same doctor, which really annoyed me because
for starters it’s always better to keep working with the same physician and
secondly because this other consultant had terrible bed-side manners and did
not seem helpful at all.
He
disagreed about his colleague’s decision to have allowed me to run and he said
that the problem was that my left quadriceps was weak and I should work on
strengthening them. Of course, my only
concern was running, which he denied me of for 4 more weeks!
That
is when the hypothetical glass shatter sound popped in my head resembling that
I won’t be running the marathon. I was even more so furious because he told me
I had weak quads, which I thought was irrelevant because all the literature I
looked up and all the experience shared by fellow ITBS sufferers had stated
that weak glutes/hips were the main cause behind ITBS.
He
referred me to the physiotherapy department, which I then found right next door
to the orthopedic department I was in. I waited about 10 minutes before it was
my turn with the physiotherapist, who seemed friendly and willing to answer
questions. I told him about my confusion with why I should be working on my
quads, when it is a glutes/hips issue and he gave me a very abstract answer
which if I remember correctly was something about the whole kinetic leg chain. He
proceeded to use therapeutic electropathy on my left leg to reduce said
inflammation, as well as prescribe a set of quad stimulating exercises while
lying on the examining table. The session did not take that much of my time and
I was scheduled to come for a second session the week after.
I
continued to do my own home online research on the injury, ranging from reading
medical journals to fellow ITBS sufferers and their experience battling this
stubborn injury. It’s fair to say that I have year-one medical student
knowledge of the thigh anatomy (maybe not really).
Most
of what I read agreed that ITBS is a result of overuse and muscular imbalance
in the glutei and hip muscles, and the orthopedic was saying that my left
Quadriceps is weak. So I was very skeptical about this news and told myself that
I’m better off doing the rehab regimens I found online, and due to a short
holiday I wasn't able to commit to the PT at this health center and I never
paid them a second visit.
I
did all I could to maintain fitness level, and I committed to the rehab and
glute/hip exercises, and I squeezed in a few swimming sessions in a given week.
I kept waiting for the period around the 10th of January to come
around, because that would be the 4 weeks the last consultant prescribed to do
strengthening exercises and afterwards, I should be able to hit the road with
no problems. The days rolled by and I did not have any problems, nor any signs
of pain when going up or down the stairs, which was a big relief. All was good
until New Years Eve, when I experienced two sudden pain episodes that were
stronger than I ever had after running. It was very frustrating because firstly
I had been committed to my rehab, and secondly, I had not been running!
The
pain was excruciating, it literally felt like a knife was rubbing my femur bone.
For me that was a wake-up call that I needed to seek professional help with my
physiotherapy, but not from the previous ones I had visited. That is when I
began using my internet searching skills to find something more reliable in
Muscat, and that is when I came across this one Osteopathy center which
specializes in Osteopathy, physiotherapy, sports massage and other helpful
services. I checked their website and one of their slogans read: “We give you
back what you lost” which really appealed to me so I contacted them to see if
they could help me get some active release technique and they said that I could
have an appointment with one of their two sports therapist, and that sounded
good to me.
So
on the 7th of January I headed over to their office anticipating
what the physiotherapist would say. I gave her a brief summary about the
details I had been rambling about above, and after I finished she asked me
three questions, the first being if I had ever broken or twisted my ankles,
which I did, twice actually had I sprained my ankle before, but fortunately
never broken. She asked me if I drink enough water, which I thought I did, but then
came to realize over the course of the following days that I didn't. Unfortunately
I can’t remember the third question she asked.
She
then had me stand up barefoot and it didn't take her more than a half a minute
to notice something unusual with myself. That was that my right foot was dead
flat, and my left foot had a normal arch.
My friend had pointed this out to me a couple of years ago, but it
didn't strike me of any importance back then. She proceeded to examine me while
lying down and she explained how this flat foot makes my right leg shorter,
which makes the left –injured- leg strained due to the hip drop, and how this
leads to my left knee turning inwards which makes the IT band compensate for
stabilization. She went ahead and stretched the hell out of my left IT band and
then used an ultrasound machine to help with any said pain in the lateral knee
aspect where the IT band inserts. I told her about the half marathon I wanted
to run and she made a “I don’t think so” face and said no promises. We
concluded our sessions by the fact that I needed to make special orthotics (shoe
insoles) to create the arch needed in my right foot, and she advised me to go
ahead and run and test the situation.
So I
did both those things on that Wednesday, first I went ahead to the orthotics
center they recommended in the osteopathy center, and had one of the workers
take my foot print size on an A4 paper and then matched it with the default
insoles of my ASICS running shoes. He said that the insole would either be
ready by Thursday or Sunday!
Later
on during that Wednesday, I wore my socks, tied my shoe laces and hit the road
for a short, easy pace run to see where things are. I ran two kilometers at a
6:15 min/km pace and I was over the moon that it did not hurt me during or
after the run.
Thursday
rolled over and I was still happy that there was no pain, and I was further
more happy (and skeptical) after the phone call I received from the orthotics
center saying that my custom insole is ready for pick up. I had my friend do
the honors because I had field work. Later that night I went ahead and picked
up the insole only to find out how thin and light the material is, and that it
only cost 10 O.R. (26$) which can be a minor indicative of the quality.
I
spent the next few days breaking in the insole by wearing it and walking around
my home to get used it before actually going ahead and running with it, because
that is never a good idea, which I eventually ended up doing just a few days
after, on the 11th of January to be specific. This time I ran 2.15
kilometers at a 5:56 min/km pace and my IT band did not complain. The insole
however, was hurting my outer arch part of the sole, but I thought it is a
common thing to happen when you start wearing these things.
My
third run was on Tuesday and I upped the distance to 3 kilometers and I was
still wearing the orthotics. Same experience, no IT band irritation, although I
was still feeling stiffness in my left knee in comparison to my healthy right
knee but I think that it is beyond normal to feel this way.
My
next PT appointment was on the 14th of January and I took my new
insoles with me to present them to my sports therapist and my skepticism was in
place, as it turns out that these were of low quality and by no means were they
custom made. During that appointment I came to learn more about the nature of
the injury in my case and its relation to my foot arch abnormality. It turned
out that because of my bio-mechanical error, my injured left knee is turning
inwards when I land my foot on the ground and that places a huge pressure on
the IT band to compensate and stabilize the knee.
After
stretching the hell out of my left IT band, and applying some ultrasound
therapy it was time for some exercises. The exercises she prescribed were
focusing on strengthening the Vastus medialis, which is a part of the of the
Quadriceps muscle. That is when I had an internal “Ahhhaaa” moment remembering
what the previous orthopedic consultants were mumbling about, but what the
failed to do is link the information in an understandable way that makes sense
and takes the whole picture into account.
The
exercises were simple to perform, with difficulties ranging from easy to
burning. There were 3 exercises, 2 sets each. I decided to add them to my own
rehab routine I was doing at home which focused on glute and hip strength.
Friday
came and I ran a simple 3 kilometers at 5:52 min/km and I was fine. I decided
to hit the beach for a barefoot run on Monday for its numerous benefits and it
was a nice run, with the only annoying part being that the surface was not
leveled enough, sort of cambered so to speak. No pain, just discomfort at
certain times.
Wednesday
rolled along and I had my third PT session which I could honestly say that it
was my favorite 45 minutes of the week due to the relief I get from the
stretches, not to mention all the knowledge I was receiving while
rehabilitating. Later that day it was time for my second run focusing on
gradually increasing my cadence by no more than 10%, so I ran another 3.2
kilometers with an average cadence of 155 steps per minute and paced
5:35 min/km, which - for me - was a fast pace run taking into account that I was
recovering from an injury. I was still feeling good during and after the runs.
Increasing
cadence have multiple benefits on the long-term, including less ground contact
time which means less impact force on the joints, so I made my next run on Friday
also a cadence-based run and it was 3.3 kilometers of pain-free running.
Monday,
the 26th of January ticked on the calendar and it was time for my
last run before the Muscat Marathon 2015 10K race which I finally settled for.
At 3.9 kilometers, it was the farthest I ran in well over a month, and I was
over the moon for it not having me adjust my running gait or walking with a
limp afterwards. One last PT appointment before the race and I was given the
green light to participate.
The
big day came – the moment of the truth – and it was a day with mixed feelings.
Feelings of anxiousness, happiness, a little bit of sorrow that I didn't manage
to run with the big boys, but all in all, deep inside I was a bit afraid that
at some point I would have to slow down or even stop and quit if the pain
decides to knock on the door again. I was running the race with a friend, and
we decided to run side by side, going along by cadence and not pace. I set my
Garmin to be in the range between 155-160 spm, and off we went. The race
started at 8 AM sharp on a lovely sunny day with air temperature of just 20
degrees Celsius. Kilometer after the next, I was feeling fine, running at a
higher cadence than my preset range for the most parts. NO PAIN. I kept going,
without caring much neither about my time nor about my pace, I simply wanted to
finish the race without feeling pain. It wasn’t until the 9th
kilometer where I felt a slight twitch, but it was a split-second kind of a
twitch and I focused on not letting my knee drift inwards and all was fine. We
decided to go for it in the last hundred meters or so and we crossed the finish
lines at 52 minutes 59 seconds. Not my fastest 10K, but definitely not my
slowest either.
It
was a glorious day; the joy of achieving such a goal after months of suffering
is something beyond description. I surely wish that nobody reading this shall
endure the mental and physical agony of this stubborn injury, but in case you
do, know that it is not the end of the road.
So,
looking back at it, what did I take away from all this?
Well,
other than the fact that I’m very well familiar with the leg anatomy by now,
there are a couple of key notes that I want to share that might be helpful in
approaching such an injury.
1.
If
in pain, stop running and consult a sports physician: Seriously, I can’t stress this enough. Although my first two
orthopedic consultants weren't terribly wrong, they weren't very helpful in
assessing the roots of the problem either. It is much better to cut to the
chase and consult a sports physiotherapist to diagnose your specific problem.
2.
The
Internet can be right, but also tricky: If
you decide to diagnose yourself on the internet, you might be lucky to find a
lot of fellow sufferers of the same injury, but the problem is that an injury
like ITBS can arise from several factors, and it is not a “one size fits all”
kind of an issue. Most online material stress that it is a problem of glute/hip
muscles, where as in my specific case, the weakness was manifested in the Vastus
medialis (Quadriceps)
3.
“Check
yourself before you wreck yourself”:
This means prehab is always better than rehab. Even if everything seems alright
at the moment, nobody is perfectly symmetrical, and any major imbalances in
your body can manifest overtime to form injuries. It is better therefore to
dedicate a part in your routine for some running specific drills, whether it
being strength, balance, mobility or whatever your weakness is.
With
all that being said, I hope you can enjoy a pain-free running life by avoiding
the necessity of going through prolonged hiatus and rehab.
Cheers,
Harith.
