Iliotibial Band Syndrome

As I mentioned in my race report, I have come down with IT Band Syndrome (ITBS) outside my right knee.  I had the exact same episode in March 2009 on my left side so it's an all too familiar feeling.  I haven't run in 7 days because of it causing a wave of running depression and realization of how important it is for my day-to-day living.  Since I am in grad school for PT I wanted to share some facts and experience with ITBS should you ever have the unpleasant experience of having to manage it.  Some anatomy for starters: the ITB is a thickening of the connective tissue surrounding your thigh.  All muscles are sheathed in usually thin connective tissue called fascia but in the leg is thickens quite dramatically on the lateral aspect of the thigh and the two main muscles that connect to it are the tensor fascia lata (TFL) and gluteus maximus (GM).  The TFL is located just lateral to your anterior superior iliac spine (ASIS) which are these bony prominences of the pelvis on your front side. You can easily palpate them on yourself: you have one on each side.  If you move your fingers 3cm to the outside of both ASIS and 1cm down you'll feel the small muscle which is the TFL.  Now run your hand along the outside of your thigh until you get to your knee; the whole thing is the ITB and it's insertion points in the area are vast: lateral patellar retinaculum, fibular head, Gerdy's Tubercle (tibia), biceps femoris (lateral hamstrings), and vastus lateralis (quadriceps).  The TFL does several things: flexes your knee when it's <20 degrees, flexes and internally rotates your hip.  When you flex your knee at about 20-30 degrees (from a standing position) a portion of the ITB that was infront of the lateral femoral condyle of your knee glides across it setting itself up behind the condyle.  To allow this smooth repetitive transition there is an underlying bursa, a fluid filled sack lying between the bone and ITB allowing an almost frictionless glide.  The school of thought behind why the ITB is even there is to keep the vast musculature of the thigh "in check".  One of the events that happens to the ITB if not properly managed is adhesion formation to the underlying muscles and superficial skin that doesn't allow correct biomechanical properties to take place.  This may lead to more pressure on that femoral condyle thus disrupting that smooth gliding occurring everytime you flex your knee.  Friction starts to occur damaging the tissue and bringing in inflammatory agents to the area.  The more swelling there is the more pressure and less room there is for the ITB to function. Therefore, the more you flex your knee while in this phase, more inflammation sets in, irritating surrounding nerves and activating pain stimuli. You can see how this would become a vicious cycle if left unchecked. In March 2009 this happened to me during a trail race and I couldn't bend my knee 5 degrees without creating severe pain.  There are other biomechanical reasons why the ITB can cause a lot of problems: the latest research has been pointing to the hip musculature to control femoral rotation (weak hip extensors/stabilizers: gluteus medius), shortened hip flexors (which causes the TFL to be overused), quadriceps, adductors, and hamstrings.  So how to manage this type of functional injury (I am not addressing structural dysfucntions such as leg length discrepancy, tibial varus, etc) :

1) decrease inflammation: as long as there are inflammatory properties in the area you cannot begin the healing process. Use ice religiously and anti-inflammatory medications (ask your physician)
2) use a foam roller to make sure the underlying fascia is seperate from the superficial skin and muscle. One may use skin rolling technique to determine areas of adhesions.
3) gluteus medius strengthening, hip external rotation strengthening
4) lengthen shortened musculature of hip and knee (to restore biomechanics), especially adductors on affected side because of possible reciprocal inhibition of glut medius if restricted and overused as hip stabilizers
5) deep friction mobilization at tender site (to break up scar tissue and decrease pain)
6) avoid running on banked surfaces (ie side of road)
7) cross training/rest

See how things react after certain self treatments. Not everyone is the same so things that might work for one person isn't necessarily going to be as effective for another.

So these past 9 non-running days I have been doing most of the above while taking both steroidal/non-steroidal anti-inflammatory medications (Prednisone and Meloxicam).  It has been improving but truthfully it's been quite depressing not running. These moments certainly make me aware that I need to practice what I preach.  Flexibility and strength: how do I expect to have a healthy body overtime when I don't keep it well maintained? The fact is it constantly needs attention and care, especially with the amount of work it goes through.  I also am doing a research paper on barefoot running vs. running shoes in relation to runner's injuries and rehabilitation. I know this is a new field so the research might be a little on the thin side but I am quite interested in what I find. I'll keep the blog updated when I delve into the research. Now I am obviously not a PT yet but if you have any musculoskeletal related questions I can certainly answer them the best I can using my current knowledge and experience. Just leave a comment.

Afterthoughts

Now that I have recounted the story about my experience of the race in the previous post I think it's a good idea to look back on the lessons learned from this new experience.  I fully understand now that the longer the race the more magnified the small things are.  The main thing I come away with is staying on top hydration and diet.  I started the race holding myself accountable of how many gels I would consume per hour and water intake, but as the day wore on that seemed to be less of the case.  I'm not sure if I was just taking it for granted or because I lost track but lesson #1 is: stay on top of hydration/dietary/electrolytes. It can make a world of difference in how one feels mentally and physically.  Lesson #2: I need to start taking care of my body a bit more in terms of gaining and maintaining strength and flexibility.  Going out running is great but doing some strength and flexibility is going to be very important in maintaining longevity.  It will also indirectly help with running performance.  This last point is not so much a lesson than observation: experiencing new things is a key principle to living.  As much as I was nervous about running the distance I was very curious and interested on how I would react beyond my zone of comfort.  New experiences enrich life and allows the opportunity to observe things in a different light because sometimes I find myself feeling quite stagnant in terms of fresh new thoughts or perspective.  

Rock'n River 50

Waiting for the start

Some delirious night about a month and a half ago I decided I wanted to try to qualify for Western States 100 next June and I needed a 50 mile race that needed to be completed in less than 11 hours. I browsed and what I found was the Rock'n River 50: a 50 miler in Auburn, CA just outside of Sacramento which coincidentally is where the Western States finish line is. It's the reverse route of the classic American River 50 that is run in April.  My training since my Bulldog 50km in August had me running 28 days per month, including one longer trail run of 2.5-3hrs every week.  The day finally arrived and in all honesty I had been quite nervous about the race.  

 I have never walked, run, or hiked 50 miles in one day before and frankly I wasn't sure if I would be able to make it.  I am usually pretty wiped after a 50km race so how the hell was I going to finish 19 more miles?  Megan, who drove, and was my crew, said I was having these mini convulsions in the middle of my sleep the night before.  The run started with a delay because the bus that was supposed to be shuttling people to the start line hadn't shown up yet.  15 minutes later the race was underway and I felt really good from the onset.  I kept telling myself to keep a good rhythm and keep my stride short and light.

The course is quite beautiful as you wind along this great single track along the American River.  I hooked up with a small group of people from the onset and it was fun just running and chatting.  Then I started to go off on my own feeling good and staying in tune with my running.  Just before the 22 mile aid station I spent five minutes looking for the pink ribbon, which delineates the course, but of course there was no ribbon until someone shouted from afar that I had to loop the parking lot and find the aid station. I was absolutely confounded as to why there wouldn't be an obvious ribbon placing showing the way.  Unfortunately, this would be a reoccurring theme. I got to the aid station as other confused runners were trying to find their way to the aid station.

Rolling into mile 26

I soon arrived at the mile 26 aid station feeling fantastic.  I was immediately told that I was in 10th place overall so I got what I needed from Megan and took off.  I was moving steadily along this wide fireroad keeping an eye out for the sparsely placed ribbons when I saw a ribbon veering right into a 1000 ft climb over an unused trail. So I start climbing this thing wondering where this thing was taking me when all of a sudden I arrive at the top where about 4 junctions present themselves and no other ribbons to be seen except orange ones. I spend 8 minuted frantically searching on and I blindly pick one going steeply downhill. A man suddenly coming up the hill tells me that someone has been supposedly messing with his ribbon placement and that this climb was completely unnecessary. He points me in the right direction and I finally make it to the aid station where I see runners that I know I passed earlier on resting there. They tell me they know this course and took the correct flat route to the aid station gaining about 20 minutes on me. At this point I am livid and Megan sensing that tries to calm me telling me that it's over and to just continue on (turns out others didn't keep their feelings to themselves at that aid station).  I soon depart and venture into unchartered waters. The furthest I have ever gone is 32 miles so I am quite curious on how my body reacts.  I make it to the next station in tact but finding it difficult to run on my own.  I hook up with Craig Sowash and we run together instantly forming a bond and making the running easier.  We are easily staring down a sub 9:30 finish. One mile before the mile 43 aid station I start to get familiar sharp pains on my right lateral knee everytime I bend knowing that I am starting to get tendinitis in my illiotibial (IT) band and like a positive feedback loop, the pain gets progressively worse with each bend. 

IT band really starting to bug me

So I was resigned to walk and shuffle with a stiff leg, keeping from bending it. I soon saw the finish and did a quicker shuffle making it in 10 hours 0 min 0 sec.  The ending was bitter sweet. I was pleased with the time, qualifying for Western States, finishing my first 50 miler but also knowing I could have gone much lower were it not for the ribbon screw ups and the IT band issue. I was also quite nauseated the last 7 miles as well probably from taking too much ibuprofen in hopes of calming my knee down and not taking in enough electrolytes.  I ended up finishing 19th overall and 2nd in my age group. I want to make a special mention to my girl Megan who was absolutely stellar in accompanying me; driving to and fro (12 hrs total), being my crew and meeting me at each aid station with goodies, and being there as psychological support.  Also to the wonderful volunteers there who clapped at every aid station and helped me when I needed it. Also special thanks to the parents and wife of Craig who also cheered me on and were great company for Megan.  They let her follow them to each aid station because of the lack of correct directions. 

School Obligations v. Backcountry Desires

Form your own path or follow other ones

As I drove to school today I did not want listen to any of the podcasts I downloaded on my ipod because I needed to be able to turn all my focus on the art of contemplation.  The night before I stayed up until midnight dabbling online about future adventures I could take and it left me in an impatient state of mind. Inspiration struck and I wanted to go on a trip right that moment with school having the potential of becoming a very distant memory. Fast forward three days later and I'm sitting here 1040pm Sunday night with an exam in morning wishing that I was done with school.  Listening to nostalgic Coldplay songs I think about the potential of the time that is currently occupied. Right at this moment I could be planning a backcountry trek through the Colorado Plateau in Utah via the Hayduke Trail.  Alas, that is not the case.  There is only this life; the odds of me sitting, breathing, thinking at this moment is beyond my understanding. So what the f*** am I doing here sitting in a goddamned chair in front of a computer.  The answer is that I am realist.  What I do understand is why I delved into the field of PT.  I can say with full authenticity that I very much like physical therapy and I can't imagine another field of academia I could be in.  The complexity of movement and it's practical and functional application.  However, the original intention was simply to provide a means for me to have a good trade, modest income, job security, and the certitude of having time for myself; whether it be for backpacking, thinking, playing, running, or anything! This is what I truly value in the highest order.  So these 3 years in grad school (now 1.75 left) is the price I pay for a lifetime of the above things. Not a bad investment.  (I should also mention that there were the undergrad studies I endured since 2006).  I will be 29 years old when I finally have my license and the first thing I am going to do is backpack the 800 mile Hayduke, Fall 2012.  Then it will hit me that I am finally free of academia and can live my life and do what I truly want to do.  Travel and experience life.  I can understand that career oriented people will delve into their profession, get credentials, earn higher degrees,  participate in research etc; and I know I can have that kind of drive for that type of career. However, what is sacrificed is time and that is not something I will give up. It's too precious, too valuable, too important.  Don't get me wrong, I plan on becoming a good therapist but I don't see myself dedicating myself to the degree of complete immersion. I will have my head out of the water looking for adventures and opportunities.  What is life about really? I interpret it simply as living it; experiencing this globe and the nature that bore us.