Yesterday, we talked about how restrictions behind the knee alter the mechanics of the knee itself. One way to compensate around those restrictions is to shift the workload to the smaller patellofemoral joint. Over time this kind of overuse can lead to patellar tendonitis or patellofemoral syndrome (PFS). In today’s post, we are going to talk about a different type of compensation and how it can create injuries like IT Band Syndrome and Pes Anserine Bursitis/Tendinopathy.
IT Band Syndrome vs Pes Anserine
When the large muscle groups (quads, hamstrings, glutes) are either a) unable to do all of the heavy lifting or b) forced to work around restrictions getting in the way, they will start to rotate in search of help. This means we are moving from big muscles to small muscles that are less equipped to handle the strain. At the knee, this means moving from the patellofemoral joint to the tendons attaching on either side of it. On the outside (in blue in the picture above), we have the IT band. On the inside (in purple), we have the pes anserine insertion. An easy way to think of both is that they help stabilize the knee, one on the outside and one on the inside. Shifting the workload to either requires the whole thigh to rotate so that these structures can be called upon to act as movers versus stabilizers. That may help buy you some time, but that rotation will cause the tendons to rub on the underlying structures creating a friction injury.
What does that mean?
Why is that important?
While there is a normal degree of rotation that happens in the leg, it’s important to realize that the amount of rotation that it would take to cause break down in these tendinous structures is not normal. The rotation here is being used to compensate against something else, giving you two problems instead of one to figure out. Let’s look at each injury one by one:
- The IT Band is particularly vulnerable when the knee twists in. This could be happening in the last part of your stride (or the bottom of your pedal stroke) when instead of using the glutes, quads, and calves, you are forced to work with the quads, and inner hamstrings/adductors. As those muscles pull and the rotation happens, the IT Band rubs over the underlying lateral quad muscle creating friction. Prolonged friction can lead to inflammation and pain moving the knee. Another example of how this can happen is in weightlifting. As your drop down into squat position, you load the hamstrings and adductors before pushing back up. If there are restrictions there, the knee can rotate in to try and help. That rotation will then create that same friction along the lateral quad.
- Unlike the IT band which rubs against underlying muscle, Pes Snserine injuries usually mean inflammation in the underlying bursa or in the tendons themselves. The rotation mechanics are the same, except for one thing. The muscles that create the Pes (aka the inner hamstrings and adductors) are pulling versus getting stretched out of position like the IT band. This typically happens in situations where the quads are unable to handle the workload and instead of pushing yourself forward, you are forced to pull yourself forward. In fact, if that pull is strong enough, it can also be why the IT band is getting pulled out of position in the first place. This is why sometimes that knee pain moves around from the inside to the outside of the knee.
So how do I fix it?
The important thing to realize with these injuries is that we need to work backwards through the layers of compensation (normal knee -> knee mobility loss/strength imbalance -> rotation -> injury). Think of it like walking down the wrong road. To fix this, we need to walk it back first and then start moving in the right direction.
- To fix the rotation, we need to start by loosening up the muscles along the inner thigh to create slack so that we can rotate the femur back into it’s normal position. Depending on where your symptoms are, this could also include work on the lateral hip/thigh and shin to remove the strain from the IT Band and it’s attachments.
- Once the rotation is under control, we then need to go back fix the restrictions and imbalances that are limiting the tibiofemoral joint in the first place. Are the mobility restrictions limited to the muscles behind the knee? Or are the joints on either side of the knee also contributing? Are the muscles on both sides of the knee strong enough to support the activities or has the imbalance started to work against this?
- While fixing the underlying mechanical issues to address the compensation, and the cause, we also need to heal the injury itself. In both Pes Anserine and ITB injuries, we need to cure the inflammation that is causing your symptoms.
In both of the courses now available on the ATA site, you will be working to address both of these injuries using self massage, mobilizations, stretching, kinesiology taping and strength work. Head over to the body map and click on the knee to check them out or drop me an email if you have any questions.
Tomorrow we dive into quad and hamstring muscle strains.