Lateral knee pain. by Carl Fisher FHFS, GSMA

Many martial artists are now cross training and using weight training and running in their routines.  The objective of introducing weight training is to aim perform exercises that will enhance certain movements within their art.  A kickboxer will use squats to help develop explosive power when kicking and a wrestler will perform bench presses to make his bridging of an opponent that much sharper.  Running is done to improve cardiovascular performance and is necessary for kickboxers and the like if they are entering tournaments.  The squat will invariably be performed by all martial artists in their workout as it is such a good all round exercise for the legs.  However, the body now has an extra burden placed on it and extra wear and tear on the joints and muscles.  Knee pain is the result of over-training and poor warm up and cool down routines and can represent a serious threat to anyone engaged in regular weight training.  Workouts are missed by persistent nagging knee pain and will certainly hinder day to day activities as well.  There are numerous knee complaints and this month, the focus is on lateral knee pain.

An athlete experiencing a sharp, stinging pain on the outside if the knee, possibly painful enough to cause a limp, may be suffering from iliotibial band syndrome (ITBS). The iliotibial band is a long ligament-like structure running along the outside of the thigh, that is formed with the tendons of the gluteus maximus (buttocks) and tensor fascia latae (Thigh) muscles

Whilst weight training, lateral knee pain can be caused by squats, lunges, hamstring curls, extensions and any motion that involves repetitive flexion (Bending) and extension (straightening) of the knee. Runners may experience the pain when running uphill and downhill and on banked surfaces.  Correct diagnosis and treatment are vital to allow the athlete to return to a level of pain free activity.

The head inserts into the lateral condyle, a protrusion, of the tibia (shinbone). It connects the ilium, the large flared portion of the pelvic bone, with the upper part of the tibia.  When the knee is flexed more than thirty degrees, the ITB lies on or behind the lateral femoral condyle, the bony prominence that makes up the upper and outer portion of the knee joint.  When the knee is extended the ITB lies in front of the lateral femoral condyle.  Repetitive flexion and extension move the ITB back and forth over this bony structure.

Normally, this mechanism will function correctly and the knee flexes and extends without pain.  ITBS can develop in a number of ways, most commonly from poor training habits than anything else.  A sudden increase in intensity, whether in the amount of weight or number of reps or a runner increasing distance or training on uneven ground may develop lateral knee pain.  One must not forget that the body’s own structural abnormalities can cause an attack.  These include a tight ITB from pelvic torsion, sacroiliac joint abnormality, pelvic obliquity and foot pronation (foot turning inwards) with excessive internal tibial rotation (shinbone turning inwards).

In most cases, an evaluation is straightforward.  The athlete will complain of knee pain brought on by repetitive flexion and extension, and a limp may be present following exertion.  Swelling is not usually evident and there is no history of acute trauma (an instant injury such as falling over and hitting the knee on a hard surface).  Full weight bearing on the affected leg with the knee in thirty to forty degree flexion will reproduce lateral knee pain.  This being the ITB coming into contact with the lateral femoral condyle (protrusion on the upper and outside area of the knee).  The athlete will lie on their back with the knee bent to 90 degrees.  The therapist then applies finger pressure over the ITB insertion at the lateral knee and extends the leg.  Pain occurs at approximately thirty degrees flexion.  The tightness of the ITB can also be assessed by the Obers test.  The athlete lies on the unaffected side with the hip and knee flexed to flatten out the lumbar spine.  The therapist grasps the lower calf of the affected leg and flexes that to ninety degrees.  After bringing the thigh in line with the athlete’s torso to maximally lengthen the ITB the doctor brings the affected leg toward the table.  If tightness is involved, the leg will remain elevated in proportion to the amount of shortening of the ITB.

Thankfully, treatment of ITBS is rather straightforward.  Ice packs, applied fifteen minutes every two and a half-hours, will reduce acute pain and intercellular fluid accumulation.  Always place a towel between the ice and skin.  Non-steroidal anti-inflammatory medication will assist in pain control.  Electrical muscle stimulation (EMS) is a very good form of physical therapy as it will help trigger points in the gluteus maximus/medius and tensor fascia lata muscles.

When the acute pain has been reduced then ITB stretching is begun.  The athlete lies on a table on the unaffected side with that side’s hip and knee flexed to flatten out the lumbar spine.  The affected leg is brought behind the torso, with the injured knee straight, and the leg hangs off the table or bed.  Gravity will stretch the ITB.  The next stretch is done standing with both knees straight.  The affected leg is brought behind the body and as close to the unaffected side as possible.  The athlete bends their torso as far as possible towards the unaffected side.

The athlete should continue to exercise but avoid the activities that worsen the pain and that usually means avoiding running at all costs.  Lower body weight training can be performed with certain modifications.  The aim of training during acute injury phase is to minimise losses rather than to maintain peak strength levels.  NEVER train through an injury in the hope it will go away, it may do in some cases but will always come back in the future and with more serious consequences.

Squats can be done in a range of motion that will avoid pain, for example, from standing to a bent knee position of thirty degrees (ITBS pain usually occurs at thirty-degree flexion).  Back squats, partner assisted, can be done on a Smith machine going from a bent knee position of ninety degrees to a semi-erect position of forty-five to thirty degrees of knee flexion, which will avoid the painful portion of the range of motion.

Leg presses are done from a bent leg position to a semi extended position between thirty to forty-five degrees of knee flexion, avoiding pain.  Quad extensions can be done from ninety degrees of knee flexion to an extended position of forty-five to thirty degrees.  Hamstring exercises are done from a straight-legged position to a bent knee position of thirty to forty-five degrees.  Calf exercises need no adjustments since they are done with straight legs for the gastrocnemius or in a seated position with knees bent at ninety degrees for the soleus.  Swimming can be done to help maintain cardio vascular levels, concentrating on the front crawl rather than the breaststroke.

After two to four weeks, when acute pain has subsided and the orthopaedic tests that reproduce lateral knee pain no longer do so, the athlete can return to a more complete range of motion during lower body weight training.  As you can see, the body takes time to recover from an injury and there are no short cuts in this area.  Athletes should look hard at their current training routines and see if they are doing correct warm up and cool downs as well as stretches.  They need to be done in a logical order and not haphazardly.  Read up on this area at your library or buy specialist books on stretching and the like.  The body is an amazing piece of evolutionary engineering and is flexible, but it will not tolerate abuse indefinitely.  Always listen to your body and rest when appropriate or train another area of your sport that will avoid the injured limb as much as possible.

This information is for educational purposes and is not intended to replace the advice or attention of healthcare professionals.  Always consult your doctor for diagnosis and treatment of health problems.

Carl Fisher is a Sports Therapist and 2nd Dan Black Belt in Tetsu No Otoko Ryu Applied Ju Jitsu under Professor Trevor Roberts, 8th Dan.  He operates a mobile therapy service in the Greater Manchester area and is available for seminars and competition attendance across the UK and abroad.  Carl can be contacted by athletes, coaches and promoters on 07748 900 334 or by e-mail at kippa37@hotmail.com.