Marathon Training and Runner’s Knee

Runner’s Knee: The Dreaded ITB!

It’s getting to that time of year again where you’ll start to notice the seasonal epidemic starting to spread across London that is… the lesser spotted Marathon Runner. They are head-to-toe in florescent running gear, camelbaks on, running morning, day and night, gradually building up their mileage in the hope they make it to the start line on race day… I know, because I’m one of them!

Unfortunately, 50-70% of people training for a marathon don’t actually make it to race day due to injury. Training for a marathon requires not only a lot of physical and mental strength, but a huge amount of time and is not advisable for a non-runner.

Most of us do not consider running as trauma, but from a mechanical perspective that’s exactly what it is. Not extreme marked trauma like being hit by a car, but much less understood micro trauma which comes about from lower force repetitive loading of your body. When we run we experience a period of flight, whereby both feet are airborne at the same time. Once we land our whole body weight is taken through one leg and, when combined with ground reaction forces, this has been shown to be equal to 2-3 times our body weight. This force is also applied very quickly as we essentially transfer weight from one leg to another, which compounds the load our bodies have to absorb further.

Now, consider during a marathon this loading cycle is repeated between 30,000-50,000 times (speed depending). Let alone the 30-40 miles a week during training, the 16 weeks prior to race day. That is an epic amount of steps. As if this isn’t enough, our bodies also have lots of asymmetries. In fact, in my clinical experience, it’s freakier to be perfectly symmetrical, not only in terms of flexibility and strength, but also structure, i.e. one foot longer than the other, one leg slightly longer, slightly differently shaped hip sockets, knee alignments, etc. This means that different body parts will be under slightly different loading, hence why one knee or hip can cause problems whilst the other doesn’t.

That’s the bad news, but now for the good news! Our bodies are AMAZING, as they are made of biological (living) tissue that are able to adapt to this repetitive loading. Tendons, ligaments and fascia proliferate more cells and increase their tensile strength, bones become denser and muscle more efficient. This response can be hugely beneficial to our health, not only in the short term, but recent studies are showing the longer term benefits against conditions such as osteoporosis. However, they need TIME to adapt.

Unfortunately, this period of adaption is often overlooked with long distance running. This can be a very significant contributing factor in the most common running injuries: shin splints; calf strain; Achilles or patella tendinopathy; piriformis syndrome; lower back pain, to name a few. Even the countless blisters are in no small part adaptation related, as skin also thickens in response to friction. However, the most common distance running injury is the dreaded ITB, a.k.a. runner’s knee! The clue is in the name.

The focus of this blog will be to look at this condition in greater detail so we better understand and can hopefully prevent you becoming a victim.


The ITB (illio-tibial band) is a thick band of connective tissue called fascia running from the outside of the hip down to the outside of the knee. It plays an important role in stabilising the knee, especially during weight bearing activities such as running. Arguments arise in literature as to the direct cause of ITBS. Research has previously shown that, as the knee flexes and extends during running gait, the ITB is being rubbed continuously over the lateral aspect of the femoral condyle, leading to the ITB becoming inflamed and painful, also known as ITBFS (illio-tibial band friction syndrome). However, more recent research indicates that it is caused by the compressional force put on the ITB at 30 degrees of knee flexion, which is more likely. Either way, both theories agree it is to do with the abnormal compressional forces between the ITB and the lateral femoral condyle. So how does this occur in the first place?


ITB is often caused by altered biomechanics within the lower leg, a mechanical fault, muscle imbalance or simply an increase in training. Common causes are: weakness in the gluteal muscles not being able to control the lower limb during foot strike; excessive pronation of the foot due to low or fallen arches; weakness in the core muscles causing a lack of control during landing, or weakness in the VMO (vastas medialis oblique) not being able to balance out the tensile forces of the strong ITB fascia. Usually, these weaknesses or flaws may already be prevalent in the runner, but are unnoticed until exaggerated by an increase in training volume.


ITB syndrome presents with pain across the outside of the knee. It can range from a dull ache initially, but can intensify to sharp, stinging pain. The pain can occur whilst running, also when going up or down stairs, and gradually build up. Often if left untreated, the pain will start to come on more quickly whilst running and persist until activity is stopped. In a more chronic state, it can even be painful during walking.


If you are suffering ITB syndrome, the best thing to do initially is take a break from running. Having a 1-2 week break, although frustrating, may help you actually get to the start line. The body needs rest so it can heal and let the inflammatory process do its job. Ice regularly to help reduce any swelling and act as pain relief.

Then go find yourself a therapist who knows their stuff! Manual therapy, such as deep tissue release, dry needling and friction techniques, will to help loosen of the tight muscle and fascia, allowing the knee to start functionally properly again. A strengthening program should be prescribed to work on the muscle imbalances at the hip and knee which are causing mechanical issues whilst running. Before trying to run again, you must get your running assessed. This is to evaluate whether there are any inefficiencies in your technique that can be improved to off-load the knee. Also to check if there are any compensations occurring due to the injury.

When ready, and depending on pain and compliance with the exercises program, running can start to be tested again – BUT ONLY AT THE ADVICE OF YOUR THERAPIST! Most people return too soon and take an even bigger step backwards. Be warned though: an initial return to running should be very light and probably be interval based. This can gradually be increased until full recovery has been made, when you can return to your marathon program.


If you think you are suffering from ITB or any other running related injury and would like some further information, please email your Sports Rehabilitation Specialist Em Manton on or call the clinic on 0207 374 2272.


Our team of chiropractors and massage therapists are on hand to answer any questions you may have, so get in touch today via or on +44 (0)20 7374 2272.

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