My IT band success story

I chronicled my IT band injury in real time while I was recovering, but I know when I was dealing with the injury, all I wanted to read online were success stories.  So I decided to write up an overview post about my IT band injury and recovery.

My IT band injury originally sneaked up on me while I was training for my marathon.  I had felt some knee pain here and there during my long runs, but it wasn’t anything overwhelming.  And it’s normal for me to have some niggling pains at the end of longer runs.  The first time it was anything more than that was during a 15 mile long run a couple months out from my marathon.  During the last several miles of my run, when I stopped for a stoplight, it stiffened up.  The first 5-7 steps after were quite painful, but once it warmed up again, it was fine.  It was sore the day after the run, too, but I had treated it with ice and ibuprofen and it was fine two days after the run.  Over the next few weeks, my knee would occasionally hurt during or after runs, but never badly enough that it worried me.  And the pain was always gone within a day, so I figured it was regular long run soreness.

Finally, I had the fateful run that pushed my knee over the edge.  It was a 15 miler during the first week of my taper.  My knee hurt starting out (which wasn’t unusual), but it never loosened up.  I tried to keep running, but after 8 miles, I knew it wasn’t going to start feeling any better and that I might injure it more, so I called it quits and hitched a ride home.

After doing some Googling, I determined it was my IT band.  The big giveaway was that my knee hurt less the faster I ran.  I tried to run a bit during the next week, but unlike in the past when my knee would rebound, it continued hurting.  Because I wanted to run my marathon in a couple of weeks, I decided to go the “rest” route until then and try to treat the injury with strengthening exercises after.  I stayed off the roads and did pool running and the elliptical for the rest of my taper.  Additionally, I changed the way I sat at work and stopped wearing shoes with any heel at all.  The marathon didn’t go well (I think I was compensating for my knee which messed up my go-to stride), but my knee did hold up pretty well.  It hurt a bit during, and it was stiff and sore afterwards, but it didn’t hit the level of pain I’d had a couple of weeks before.

After my marathon, recovery was the name of the game.  I had read a lot about IT band issues sticking around and causing problems for months.  I didn’t have time for that because I was scheduled to start my Ironman training plan in just over a month.  So, once I started working out again, I started strength training.  I did this part on my own.  I looked up exercises for hip and glute strength since that seemed to be the most common cause for IT band pain and started doing an hour and a half of strength training a week.  I also scheduled a free running analysis with a local PT clinic.  The physical therapist gave me some solid advice on my stride (increase my cadence and focus on a mid-foot/toe strike instead of heel strike) and suggested that I come back in a couple of weeks if I didn’t have any improvement.

I was very careful with me knee for those two weeks.  I stopped running the minute my pain felt even a little bit sharp (as opposed to achy).  Still, even with the continuing strength work and the changes in my form, I didn’t see much, if any, improvement over the next couple of weeks, so I called up the physical therapist and made a real appointment.

The physical therapist did a litany of strength, flexibility, and stability tests on me.  It turns out, my hips and glutes were actually pretty strong.  However, when I tried to actually use them, my stability was lacking.  Even worse was my flexibility.  So those two things—stability and flexibility—were what we worked on during my relatively few sessions of physical therapy.  Just a few weeks later, I was able to run an hour and a half with no pain at all.

Looking back on my experience with IT band pain, there are a few things that stand out as important to my recovery.  Here are my suggestions if you are having IT band pain:

1. Strengthen. Weak hips and glutes are the most common cause of IT band pain.  Since “graduating” from physical therapy, I’ve been faithfully doing my strength work three times a week.  I do two shorter 15 minute sessions and one longer 30 minute session.  My physical therapist suggested that I focus on a few different exercises. My physical therapist specifically had me focus on exercises that used lateral movement.  Because swimming, cycling, and running are all forward-motion sports, the muscles responsible for lateral movement can get weak or ineffective.  Specifically, he recommended I do the following three exercises:

20160614_175109
Lateral side steps using a resistance band. 
20160614_175217
Single leg dead lifts.  I use a five pound weight when they are available.  Ideally, my planted leg would not be so bent, but my flexibility is pretty poor. 
20160614_175246
Side plank hip lift to leg lift.  Start on your side with your hip on the group.  Lift yourself up onto your foot and elbow.  Then lift your leg up.  My upper body is a little crooked.  I suspect I should do a better job of keeping it in line with my lower body.

2. Improve flexibility. I didn’t see much about this particular issue online.  Sure, I saw suggestions to stretch the IT band (or rather, the TFL which is the muscle that attaches to the IT band), but I never saw anything about how a lack of flexibility in other muscles could contribute to IT band pain.  My physical therapist had me stretch my hamstrings, my calves, my glutes, and my TFL several times a day.  While I have slacked off on the stretching, I still faithfully stretch (and do leg swings) before every run.

3. Take care of your knee in your everyday life. This made a big difference once I started doing it. I am chronically wiggly, so I cross and recross my legs every few minutes.  I sit cross-legged or on my knees.  My legs are always sticking out at weird angles.  But I noticed that this was putting completely unnecessary stress on my IT band.  So I forced myself to sit with my legs out in front of me.  I stopped wearing any heel at all.  Anything that made my knee hurt even a little was discontinued or modified.  For instance, I noticed that for some reason, kneeling on the kneeler/hassock at church put some undue pressure on my IT band.  So I modified the way I kneeled so that I put all my weight on my good knee and let my bad knee just relax off to the side.

4. See a physical therapist. You’ve probably noticed that I talk about my physical therapist a lot.  I think I had 4-6 sessions in all over the course of a month.  I know not everyone has the financial opportunity to see a physical therapist, but if you do, I would suggest it.  I am so glad I didn’t spend three months doing almost the right thing while trying to completely self-treat.  I did the best research I could and put together a pretty solid strengthening plan, but I didn’t pick out the perfect exercises for my particular situation, and I missed the flexibility part.  Additionally, my physical therapist used a massage-type technique on me called ASTYM™ that I would not have been able to do myself.  I’m not convinced this was the integral factor to my healing, but it was likely helped.

5. Improve your running form. Everyone has some form weaknesses, and those can contribute to injuries.  So do what you can to improve your form and take some of the impact off your joints.  For me, it was as simple as increasing my cadence.  Once I increased my cadence, I automatically switched to a mid-foot/toe strike instead of a poorly executed heel strike that was creating more impact for my knee than I should have been.

Above all, I would advise anyone with any sort of significant IT band pain to act quickly.  If a little bit of rest doesn’t clear the problem right up, then be proactive.  Don’t just foam roll.  Do strength exercises.  Read up on running form and consider where improvements might help reduce the impact of your footfall.  Continue to take it easy on your knee as you build strength.  If the improvement doesn’t come, then consider seeing a physical therapist (if you can afford it).  It’s a pain in the neck, and it’s not all that cheap, but a physical therapist will be able to give you advice that is specific to your particular body and your particular injury.

For further reference, here are the posts that detail my IT band injury and recovery:

Hello, IT band!
IT Band Rehab
Gait Analysis
Physical Therapy: IT Band Update

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Physical Therapy: IT Band Update

Now that I have a couple of physical therapy sessions under my belt, I thought I’d give a quick update about where I am in my IT band recovery process.

(I know, I know.  Y’all have been just dying to hear.)

I decided to go to the same physical therapist that did my running analysis.  I had a very positive experience and learned a lot through that analysis, so I was confident that he knew his stuff and would be able to help me.   So, during lunch on Monday, I drove to his office for my appointment.  One of the first things he asked me as he was beginning to run me through basic strength tests was whether or not I did any cross-training.  I was a bit taken aback by this question because I found him through my tri club which I knew he remembered because he had already mentioned it.  So I assumed I was missing something and replied rather tentatively, “Well, I mean, I swim and bike…” Apparently, he gets that answer a lot from triathletes.  It turns out that one thing swimming, biking, and running all have in common is that all their momentum is focused on going forward.  That can lead to a loss of lateral coordination.  This will come back in a moment.

I was a bit surprised and quite pleased with the results of the strength tests.  Unlike most IT band problems, it appears that mine don’t stem directly from weak hips and weak glutes.  Regarding strength, I had almost full marks across the board (I had one 4+ instead of a 5… so close!).  However, despite my good performance on the strength tests, when he had me do single leg squats, he saw some instability in my knee position (basically, it was collapsing inward somewhat).  So, even though my muscles were strong enough, I lack some of the muscular coordination to actually put that strength to good use.  The one other test I failed was flexibility.  My hips are actually fine, but my calves, hamstrings, and IT bands are all very tight.  I knew I was not flexible.  But I had never connected it to my IT band issues before, probably because it never showed up on my good friend Google.  It makes sense, though, that if those muscles that surround or attached to my knee and my IT band are tight, they could contribute to IT band pain.

So I was given three bits of homework.  First, I should continue with my strengthening routine and make sure that some of the exercises include lateral movement.  He gave me a couple of elements to add to the routine, but mostly, he approved of what I was already doing.  Second, I should stretch four times a day (hamstrings, calves, glutes, and the TFL—the muscle attached to the IT band) and roll out my IT band daily.  Third, I should keep exercising as normally as I can and try to continue improving my running form, specifically keeping a high cadence so that I stop heel-striking.

He also did something called ASTYM® on my whole leg.  Basically, he beat it up.  Using these hard plastic tools, he scraped and prodded my leg until it hurt.  It was actually bruised for a few days.  The reasoning behind this has to do with your body’s natural healing response.  If you sprain your ankle, it gets swollen and bruised.  That’s because your body was doing things like increasing blood flow to the area to facilitate healing.  With chronic injuries, sometimes that process stops.  The idea behind ASTYM® is that doing minor tissue damage, you can stimulate the body’s healing response and fix the issue that’s actually giving you trouble.  To be honest, if I had read about this on the Internet, I would have been giving it the skeptical side-eye.  But considering there’s a good chance that a physical therapist knows more about physical therapy than I do, I was more than happy to accept the validity of ASTYM®.

BruisedLeg2
I bruise easily.

 

That evening after I got home from work, I prepared for my run.  I stretched well and did some dynamic drills as well as the one of the stretching sessions I was assigned as homework.  And I left for my run.  Not long into my run, I started to feel cautiously optimistic.  I felt like this might be a good run.  But I tried to hold off those thoughts until I hit 15 minutes (typically, I start to feel little twinges of pain around 10 minutes).  Fifteen minutes in, I was still pain-free.  At thirty minutes, I still hadn’t felt any pain and decided to finish up five miles (which would be my longest run in weeks).  During the last few minutes, as I was getting a little more fatigued, I could just start to feel the IT band—not pain, but I could feel that it existed.

Five miles without pain!  That’s a pretty big milestone.  I am finally feeling confident that I’m getting better.  I’m looking forward to testing out longer runs and building my running endurance back up to where it should be right now.

Gait Analysis

After dealing with IT band pain for about six weeks and listening to Rob tell me I should go see a doctor about it for just about as long, I finally decided he was right.  It wasn’t worth risking a $700+ investment to try to save $100 dollars by not seeing a professional.

So I did a quick search of my tri club’s Facebook page for a good physical therapist and saw something interesting.  A physical therapist right near my work offered free running analyses to members of my triathlon club.  Free?!  That’s only my favorite word!  I quickly called and made an appointment for 6:30am the next morning.

Because I needed to get in my strength routine before the running analysis, it was an early, early morning for me.  I was up at 4:35am, which would have been more doable had it not been just a few days after the time change.  But I managed to wake up and make it to my office’s gym in time to do my workout there and make it to my appointment on time.  David, the physical therapist, was very personable, and I felt at ease right away.  I tend to feel pretty uncomfortable and awkward around people, so the fact that I felt at ease in this new situation speaks to his bedside manner (is it still called that if someone is a physical therapist and not a medical doctor?).

He asked me a few basic questions, and I told him about the IT band pain I’d had recently.  Because it was early and I wasn’t functioning all that well, though, I told him it was on the left side when it was on the right side.  I’m really not good with rights and lefts, and I must have just gotten confused and turned around.  The test itself was simple enough.  I jumped on a treadmill and set it to 7.6 mph.  David measured my cadence and took some videos of me running, both from the back and from the side.  I ended up running for about four minutes, and then we discussed the data.  It was surprisingly simple, and he e-mailed me the still shots of me running afterwards so I can even include them here for reference.

We went over two shots from the back—one of my left foot striking and one of my right foot striking.  We discussed the following measurements on each side: the angle that my opposite hip dropped when striking the ground, the position of my knee in relation to a straight line between my hip and heel, and the position of my foot in relation to the midline.

BehindRight

My right side actually looks pretty solid on most of those points.  The angle of the hip drop should be less than 10° and my foot hits right on the midline where it should be hitting.  As you can see, though, my knee turns in a bit instead of staying in a straight line.  David said this could be part of what is causing the IT band pain.

BackLeft

My left side looks a little worse, despite the fact that I haven’t struggled much with pain on the left side.  Especially after looking at the shots from the side, I suspect I may have been unconsciously compensating for pain.  I tried to run normally, but that’s easier said than done.  On the left side, you can see my hip drop angle is right at the 10° mark that it shouldn’t go over.  No real problem there, but it’s not quite as good as my right side.  On this side, my knee is in line with the rest of my leg, but my foot crosses over the midline too much.

BackBounce

We also went over how bouncy I am when I run, or how much up-down movement there is for each stride.  As you can see, I’m moving up and down about 12.5cm every stride.  I wish I could recall exactly how much I should be moving, but I recall I was over the ideal.  David didn’t seem all too concerned about it, though, and said that my bouncing up and down as much as I was wasn’t as much of a problem as it would be if I were shorter.

SideLeft

The video from the side is where my main problem with my stride appeared.  Again, my left foot strike is worse than my right foot strike, quite possibly because I was subconsciously changing my stride with my right foot due to my recent pain.  With my left foot, you can see that the angle at which my heel first hits the ground is 14°.  That’s too much.  What that reveals is that my foot is probably too far forward and my leg is probably too straight when it hits.  You can see that the angle of my bent knee is around 8°.  It should be around 20°.  A straighter leg causes a more jarring impact and also forces your knee to absorb that impact instead of your quads. (Oh, I’m also standing up too straight and don’t have much of a forward lean.)

SideRight

My right side is better.  My foot is at an 8° angle when my heel hits the treadmill which results in my knee having a much better (though still a little sub-par) angle of 15°.  Again, I do not have enough of a forward lean, which is something I’ve heard since high school.

As we discussed my running mechanics, David also noted that my cadence was a little slow.  The nebulous “they” say running cadence should be 180 steps per minute.  David said his opinion was that the metric is a little restrictive.  Apparently, that study was originally done on elite marathoners, and he noted that we are not all elite marathoners.  Still, my cadence was 172 steps per minute which he thought was a little slow.  So he suggested I try upping it to 178 steps per minute.

He had me hop on the treadmill to try it out.  We set the pace back to 7.6 mph and he turned on a metronome at 178bpm and had me match it with my pace.  Lo and behold, my over-exaggerated heel strike was fixed!  Basically, when I sped up my cadence, I shortened my stride which caused my foot to strike closer to my body and which transformed me into a mid-foot striker.  Magic!  While it didn’t fix everything with my stride (my lack of a forward lean is just as prominent as ever), most of the more troublesome aspects looked much better.

So, with a little advice and some encouragement, he sent me out the door.  I asked him when I should come in for more IT band help if this advice and my strength training didn’t clear it up, and he suggested I give it two weeks.  If, after stretching, strength work, and form improvement, I was not seeing any improvement in two weeks, I should come back in.  I still wanted to take that week of training very easy in regards to running.  After the longer run the previous weekend, I felt my IT band could use a little rest.  A couple of days later, I did a 15 minute run on the treadmill using a metronome.  I could feel the difference in my stride, and my knee held up really well.  I was feeling positive, like there was a light at the end of the injury tunnel.

Then, over the weekend, I went for a long bike ride.  I didn’t feel my IT band at all during the ride, which isn’t surprising because I’ve never felt it on a bike, even at its worst.  The next day, I headed out for a maybe-hour-long run with the intent of stopping early if I felt pain.  Much to my surprise, even with a quicker tempo, I started feeling pain literally two minutes into the run.  After five, I realized it was going to keep getting worse, so I just stopped and walked back home.  I was at a loss after this.  Since this was the worst pain I’d had in weeks, it made sense to suspect that my long bike ride had something to do with it (correlation is not causation, but it is cause for suspicion).  However, since cycling didn’t seem to hurt, or even irritate, my IT band.  My only guess (which could be completely wrong) is that my legs were fatigued enough on Sunday from my long ride the day before that it caused my form to disintegrate faster than usual.  So, since I was told to wait two weeks anyway, I decided to avoid doing my runs on days after a long or hard bike ride.

Despite this last-ditch tactic, I get the feeling I’ll be calling up the physical therapist on Friday and scheduling an appointment for early next week.

IT Band Rehab

Disclaimer: I’m not a physical therapist or a doctor or a trainer.  I’m just your average citizen with an Internet connection. Special thanks to Brittany, Rheagan, and Allison, who pointed me in the direction of their own blog posts or strength/flexibility routines.

Recently, my IT band and I have been fighting.  I tell I’m going for a run.  It tells me it would rather go on a bike ride.  I tell it to stop being such a big baby.  It insists, in a very big way, that it is not a baby and that I should take it seriously.

Because I plan on doing an Ironman in August and because it reached a point where I was pretty debilitated, I decided I needed to get my IT band under control.  So I turned to the Internet.  Almost everything I read regarding IT band agreed on one thing—the root cause is weak hip and glute muscles.  Still, I was a bit surprised because I had never had IT band issues before, despite running a lot in high school and college.  However, a few more Internet searches taught me that it is common for cyclists to have unbalanced musculature where their quads are much stronger than their glutes and hamstrings.  With all the cycling I’ve done the past couple of years, I suspect this is what happened to me.

So, I’ve been approaching IT band recovery from a few different angles.

First, I’ve been trying to limit my IT band irritation in my daily life.  I noticed pretty quickly that things like crossing my legs and putting weird pressure on my knee when sitting irritate my IT band.  So I’ve been trying to sit like a civilized adult, with my feet on the ground in front of me.  I even lowered my chair at work because I felt the angle of my knees was better with the chair lower.  This has been a huge struggle for me.  I wiggle constantly, so not being able to cross my legs, pull my knee up under me, and just generally sit like a three-year-old during a two hour sermon has been an adjustment, to say the least.  It’s taken a surprising amount of self-control to do this.  Additionally, I have not worn any shoes with even the slightest heel.  This isn’t much of a problem for me, although it did mean that I missed the last few weeks of boot weather because my boots have a short heel.

Secondly, I’ve drastically reduced the number of miles I’m running.  I’ve been trying to “test” my knee out with shorter runs.  So far, that process has gone fairly well.  Half an hour seems to be fine.  An hour is probably still too much as this point.  It’s hard for me to know exactly how much pain is too much, but if the pain lasts after I’m done running, then I generally assume I did too much.  I’m also being more conscientious about stretching and warming up before going out for a run.  In fact, I’ve actually purchased a tennis ball and have begun to do the poor-man’s version of foam rolling with it.  I’m hoping it will keep me running while I address the underlying issues.

Most importantly, I’ve been working on building up my hip and glute strength, which is most likely the root of my IT band pain.  I’ve been taking advantage of the time before my official Ironman training program starts to focus on strength training for my hips and glutes.  I’ve been doing a longer routine two times a week and a shorter routine two times a week.  The longer routine takes me 30-40 minutes, while the shorter one takes me about 15 minutes.  When my Ironman training starts, I’ll probably cut out one of the longer sessions because of time constraints.

Long routine:
3 x 10 single leg squat (each leg)
3 x 10 single leg deadlift (each leg)
3 x 20 alternating side lunges
2 x 10 standing hip abduction (each leg)
2 x 10 standing hip adduction (each leg)
20 hip thrusts (both legs and each leg)
2 x 20 leg lifts (each leg)

Abridged routine:
3 x 10 single leg squat (each leg)
MYRTL routine
20 leg lifts (each leg)

Weights
I’ll be honest… I was pretty okay with the idea of never using these guys again.

My longer routine is mostly body weight.  However, I use five pound dumbbells for the single leg deadlifts and use a weight machine (with just a few pounds) for the standing hip abduction and adduction exercises.  With the single leg squats and side lunges, I have to focus to make sure I’m working the correct muscles (my glutes as opposed to my quads).  Using correct squat form (knees not extending past toes, for instance) ensures I’m using the correct muscles.  The first few times, I paid attention to where I was feeling the burn and to which muscles were sore the next day.  I’m confident that I’m (mostly) working the muscles I want to.

My abridged routine is much shorter (obviously!).  I do some glute strength work, but the MYRTL routine focuses more on flexibility throughout the glutes and hips than strength.  I was actually already familiar with a lot of the exercises from the MYRTL routine from when I was a hurdler, so I enjoy doing it.

(By the way, I’m not including images of me doing these exercises because you can find demonstrations of all these exercises with much better form with a simple Google search.)

This new strength work adds an extra hour and a half to my weekly load of workouts.  Even with my current pre-Ironman load, that adds a lot to my plate.  Last week, my time working out added up to eight and a half hours… and things aren’t even serious yet!  I do plan on cutting out one of my longer sessions once Ironman training picks up, but the strength work will still add an extra hour of exercise on top of my 10-18 hour training weeks.  However, I know that this kind of strength training is as important to my Ironman goal right now as cycling and swimming are, and it’s that understanding that is keeping me motivated to continue with my self-created IT band rehab, even though it’s not something that I enjoy.