Sports Physical Therapist Sean’s story of how his ITBS began in Part 1 of this blog has proved popular this month and led to a number of people requesting Part 2… So here it is, how Sean got back running after 8 years of ITBS;
You can follow Sean on Twitter via @RealSeanMcbride
My wife and I moved to Seattle, WA this past year, and I didn’t have a job when we first arrived. Seattle is an active community and beautiful city, and I had some time on my hands. I took a pretty solid online continuing education course on running. I remembered that at no time had I ever took a strengthening approach or tried to work on my running gait. I was aware of the limitations between associating pain and biomechanics, so I decided to attempt anything that would limit the loading of my knee. I knew from the research that type of foot strike didn’t appear to matter much, but it did seem that striking under my center of mass was important and that there were a few things that I could do to make that happen. While taking the running course, it struck me how the instructor continued to mention that as runners we never work on our form, yet it would be asinine for a swimmer or other athlete to never work on their form. Again, I accept that their isn’t just one running form that we should all work toward, but I felt there were definitely some things that could improve my efficiency and decrease some forces through my knee. Even with that supinated foot and varus knee – could I combine some strengthening, a little bit of sensible gait retraining, and some graded exposure? This became my project while I didn’t have a job and was adjusting to a new city clear across the country.
A 2012 systematic review by van de Worp et al. points out that their is conflicting evidence about the role of the hip abductors in runners with ITBS, but they do state that, “hip/knee coordination and running style appear to be key factors in the treatment of ITBS.” Either way, strengthening my hip and knee musculature could do me no harm and was likely a significant missing component of any half-assed approach I had previously taken. So without further delay, here was my approach to my running return:
Gait Retraining/Running adjustments:
I have seen over and over again case studies that advocate a higher running cadence to encourage a shorter stride length. Anecdotally, I do feel that in the past my stride had become long, lazy, and loud. I even remember a teammate once pointing out that it sounded like I was pounding the ground pretty hard. The running course that I took online advocated being an efficient runner. Some of the principles behind this included foot striking under your center of mass. It’s easy to say these things, but how do you achieve them? I already mentioned shortening my stride with a higher cadence, but another adjustment helped me as well. Having a higher knee drive during swing phase – or another way to think of it is that while swinging one leg forward the trajectory of my swinging foot would be through the height of my knee on the other leg, resulting in increased hip and knee flexion. This further helps shorten my stride up and gives me a chance to bring the leg down under my center of mass instead of way out in front of me with an extended knee. I did not worry about what type of foot strike I assumed – I do whatever comes natural. A video of a good exercise drill for this is here from @ChrisJohnsonPT:
With my foot striking closer to my center of mass in combination with a quicker cadence, my foot shouldn’t be in contact with the ground as long as it probably was before. The longer the foot is on the ground, the longer we have for some not so great things to happen.
Major mistakes in the past were made when I would just head out and run way too far because I believed my past career put me in a position to do so. If I wasn’t running 5-6 miles then what was the point? I had to curb this belief and make myself start with something I knew I could do: 2 miles. There is a park close by right on Puget Sound that is beautiful with a path along the water and it is 1 mile down and 1 mile back. Perfect – a beautiful place with an appropriate distance. I started by running 2 miles twice a week and never two days in a row. I knew that I needed recovery days for tissue adaptation. About 2-3 weeks into my program, I noticed pain medially and high on both of my tibias just below my knees. I was able to run through it at first, but eventually had to skip a few running sessions because it would hurt immediately on starting up. It only hurt with running and when I would test it with single leg hopping. I was actually pleased to have pain on the inside of my knee as opposed to the outside – and it being bilateral meant that my body was adjusting to newly encountered forces. Once I was able to single-leg hop without pain I was also able to run without pain. This made me remember that 2-3 times my bodyweight were going through my knees when I was running and I just needed time to adjust.
After several weeks I increased to 2 miles three times a week. Once I could do this I increased to 4 times a week and introduced my first back to back running days into the equation. For instance, I would run 2 miles on Tuesday and Wednesday, skip two days, and run again on Saturday and Sunday. I also did this for a couple of weeks before increasing my mileage to 3 miles. When I did this, I started back at twice a week and did the same progression. At the time that I am writing this, I started a new job and applied to a PhD program and my progression is currently stalled at 3 miles – which I am quite fine with. I can run 3 miles several times a week without pain, which is so much better than what I was doing before. My goal is to continue to increase my mileage up to 5-6 mile runs as many times per week as possible.
I believe that as physios a lot of us do a poor job of strengthening and we are constantly underdosing. I am guilty as charged but working on fixing this. I talked about this on a plane ride with Dr. Chad Cook as well – exercise is such a broad topic and it’s not presented well in physical therapy school. Anyway, I picked a few exercises from here and there that would target my hip and knee musculature.
One exercise I really liked was from the running continuing education course I took. It consisted of a side plank with abduction of the top leg. However, instead of holding the plank I would come in and out of the position. Once I was in the plank, I would perform abduction of the top leg and then lower the top leg back down and then come out of the plank. This on/off approach mimics running and I could tell there was a deficit on my left. To exercise my left, I have my left side down on the ground and resting up on my elbow. I ensure I am straight, then plank up, and once up I abduct the right leg. Bring the right leg back down, and then come out of the plank and then right back into it again in a controlled manner. What I noticed is that when I would go to abduct the right leg, my pelvis would drop out of the plank. This gave me something to work on that I could feel.
Image Source: Boren et al. (2011)
I also worked on single leg hip thrusters. I like this exercise as I can really feel the musculature working more than bridges that I have done in the past. The hip thruster also takes the hip through a greater range of motion and target the glutes better than other exercises;
Some other exercises I worked on included quadriceps strengthening via squats and lunges. I have a touch of patellofemoral pain syndrome on my left leg as well and know that my quadriceps muscle mass is less on that side. The quadriceps are good at absorbing shock at the knee and I know mine could use some strengthening – especially on the left. Here are some variations of quadriceps strengthening exercises I performed;
When I look back on my first encounter with physical therapy during my senior year of high school, it amazes me that no therapist ever watched me run. The only time I ever had pain was with running! There was no other way to reproduce the pain. Furthermore, I was never given any strengthening exercises. I will say this – to be competitive as a runner it would be beneficial to lift weights! LIFT WEIGHTS! Actually do strength training working off of a 1RM. I have now returned to running twice from ITBS – once with mostly stretching and a slow return to running and now again with gait retraining, strengthening, and a slow return. What do both approaches have in common? That’s right – a slow, smart, planned, graded return to running. This is so important as our body is constantly readjusting to the forces we encounter.
I suffered from ITBS for 8 years – mostly due to my own laziness and stupidity. I was my own worse patient. However, I wanted to write this blog to encourage those of you who have suffered from a long term running injury to not give up. Seek the right help and always remember there isn’t a magic bullet. Suspend your own beliefs about a varus knee and a supinated foot. Sometimes the answers are much more simple than they seem – just mix in some hard work and dedication.
Thank you Tom Goom for allowing me to write this guest post on your blog. Keep inspiring our running friends out there. Happy trails!
Sean McBride, PT, DPT, OCS
Board Certified Orthopaedic Specialist