In a recent hiking group discussion on lateral knee pain caused by iliotibial band (ITB) syndrome, many hikers recommended using a hiking pole, tennis ball, or foam roller on the ITB to relieve the pain. The ITB is a fibro-tendonous band that runs along the outside of the thigh from the hip to the the knee (see figure 1). It acts as a tie-in for several muscles in both the front and back of the hip. No matter how hard you press or push or what instrument of torture you use, the tough tissue that makes up the ITB, doesn’t elongate more than what’s needed for the muscles that attach to it to function and grow. (Don’t @me, the science is clear on this.)
Figure 1: The iliotibial band anatomy
The engineering is brilliant when it works. However, when one side of the system isn’t pulling its weight, the ITB suffers from the strain. The pain felt at the insertion of the ITB along the outside of the knee is usually because of weakness in the muscles near it. When the muscles are weak or tired, the body leans on the stability of the ITB to do the work. Like a building relies on steel supports, the structural aspects of the anatomy do some of the work of holding us upright. However, pathology and pain can result from depending on these tissues for too long.
In this system, the culprit is usually the gluteus medius, the smaller muscle that lies under the gluteus maximus. This muscle is responsible for abducting the leg (moving it away from the body). When walking, however, this muscle keeps the pelvis steady as you step forward. When the glute medius fatigues, the pelvis drops and relies on the strong and rigid ITB to hold it up. The hip flexor muscle called the tensor fascia lata tries to help, (since it actually attaches to the ITB ) but it often becomes overactive and make the problem worse. Try as you might, foam rolling won’t fix this mechanical problem.
Fixing the problem
To remove the strain at the ITB insertion on the lateral side of the knee, you’ll need to strengthen the gluteus medius. The ultimate goal for hikers is to train this muscle in a functional way to mimic how you’ll use it. However, depending on your strength and ability, you may need to start with isolated exercises. Try the following progression three times per week for six weeks to strengthen the gluteus medium and help decrease lateral knee pain.
Hip Abduction in Side-lying
In side-lying, bend the bottom leg and extend the top leg behind you. Keeping the top knee straight and the toe pointed forward, raise and lower the leg, feeling the muscle working in the buttock. Perform 3 sets of 10 to 15 reps to start. Progress reps up to 25 and add a resistance band around the legs to increase difficulty.
Modified Pistol Squat
If you're a beginner to this functional exercise, start by placing a stool or tall chair behind you. Extend one leg forward and slowly squat down, keeping your knee back and tracking forward over the toe. Stand up on the same leg, or if needed, use both legs to stand up. Progress to next level of difficulty when you can perform 3 sets of 10-12 reps comfortably.
Easy Pistol Squat
Using the same technique as with the modified version, extend one leg and the arms, then hinge at the hips and squat down on one leg. Stand up with the same leg. If you're advanced, squat more deeply. Perform 3 sets of 10 to 12 reps.
Banded Lateral Walk
In a semi-squat position with a short band around the middle of the thighs, step laterally keeping knees apart and squared position. Repeat in each direction performing 3 sets of 10 to 15 steps on each side. Add more resistance and more reps to progress the exercise.
Training works
Keeping your body strong helps prevent these problems in the first place. The Healthy Hiker training program is customized to your needs, your goals, and your lifestyle so you can hit the trail feeling strong and safe. Have questions about your hiking challenges? Reach out and let's put a plan together for you!
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