Knee pain (runner's knee / ITBS) post-lockdown, slow recover

[UpAndDownMountains]

Soon after the enforced break from hiking due to the first lockdown, I developed some knee pain which I'm yet to properly recover from. I'm seeing a physio but am interested in any others' general or similar experience of runners' knee / ITBS and thoughts on my own situation. It's a long story, sorry!

The background is, I'm 32 male, slim build and reasonably fit hiker. I've always been active and have been hiking seriously since I was 18 without any problems. In the past few years I've done big treks (10+ days carrying 10kg) in the Alps and Nepal, and my typical UK summer hike in the Lakes/Snowdonia would be multiple mountains 25km+ with 1500m+ ascent/descent in 6-8 hours. In the winter I run 5k occasionally to try and keep my fitness up, and do the odd 20 mile flat bike ride. I worked in an office full time, been working from home since lockdown. As part of my commuting and lunch stroll I used to walk 2 miles daily including 300 staircase steps up and same down.

From mid-September until mid-July (10 months) I didn't do any proper hiking. I'm a fair-weather hiker, normally I'd resume in early April (6 month gap). Neither did I do any of my commuting walks/stairs, some days I didn't walk at all but otherwise I'd do some local walking (pavements) up to 3km starting from my door. In April and May I ran 5k five times, and after that I started biking more regularly (local cycleways and forest trails). I started enjoying the bike more as it was much more enjoyable than walking in the flat urban part of the country I live in, and my fitness improved.

First proper hike was mid-July, I thought I'd take it easy and did 20km with 1000m ascent, easy grassy not steep terrain. No knee pain but my legs were hurting all-over the next day - kind of expected and back to normal the day after. Next weekend I do 15km with 950m ascent in similar terrain but a little steeper on the way down. Setting back down after lunch, I quickly start to feel minor but uncomfortable pain in the outer rears of both knees. I slow down but complete the walk, including a few km on a flat path back to the car. The following days my knees hurt even walking a few hundred metres on flat pavements.

Now I knew something was wrong, I looked up the symptoms and found it was probably runners' knee. I halted hiking for 10 days (just did 1-3km local walks), and did the NHS stretches together with applying ice. After that I ramped up slowly with rest days (but in hindsight probably too quickly) - 7km flat walk (no pain), 10km/550m hike (taking it easy, with poles, faint pain), 12km/650m hike (down with poles, faint pain), 12km flat-ish cycling (no pain). Finally I did a 13km/850m hike, there was a really steep down about halfway in (poor planning) and the pain was pretty bad even going slowly with poles. Finishing back to the car, it's only minor on uphills, but on any down or flat it's getting more painful. The poles barely help, and by the end I'm hobbling and stopping to sit down every few hundred metres.

I take another 10 day break, just local walks, stretches, and ice. It's getting better as it did last time, and I start ramping up slower again. After a bike ride and doing some DIY one day, I've unexpectedly upset it again and I struggle to walk both up and down the stairs, until late that night going upstairs I get a shot of pain on one side and then it's back to normal pain level again.

Another 10 day break. I see the cycle repeating and it's not fixing itself, so I manage to get a physiotherapy referral. Meanwhile I continue with the stretches, ice, small walks and bike rides. Any time I walk or bike a little too long (or mindlessly jog from the shop because it's raining), it starts hurting again and now I've learnt to have route options or someone fetch me before it gets worse.

The physio appointment comes round, and it's online. She has me do some exercises on camera, from which she concludes my knees are weak in terms of stability - they always want to bend inwards under power/impact. I'm assigned an exercise programme of many more squats, step downs, crab walks with band, stretches, and foam rolling. For the next 6 weeks I do these and small walks/rides, seeing the physio every other week. By the end I do a ramp up slowly with no problems until a 11km/600m hike when faint pain started to return by the end of the descent.

I figured the online approach wasn't ideal and didn't feel it would get me back to normal for my active lifestyle, so I booked to see an in-person physiotherapist. He diagnoses me with a tight IT band (ITBS) causing irritation, unsupported (not flat) foot arches, causing pronation (inward rolling) of the knee. And that previously these didn't cause issues because my legs were conditioned. Over the next few months, I see him weekly/bi-weekly for stretches, massages, and ultrasound. I'm given more exercises to do, and on advice I buy some trainers with arch support for daily use. The sessions/exercises become less painful, and slowly ramping up the hiking in parallel to build my strength back and provide indication of progress.

Then maybe November, restrictions/weather kick in again and I'm back to doing local flat long walks again. I know it's still not fixed, as I had some small pain on my final hikes, and sessioning local tiny-hills/staircases eventually bring the pain back.

Originally it was both knees. Then just the right one. Then the left one (this was the really bad one when I had to hobble back to the car, the right was never nearly as bad as that). Then both very slightly. Now the left one is perfectly fine and it's just the right one that starts hurting just on the downhills (or long walk on hard surface). The right also hurts a bit when I get up after sitting still for too long. I'm right-side dominant and my right leg is stronger.

I've racked my brains for what I might have done to cause this, can't think of anything aside from the lack of strenuous hiking causing deconditioning, and ramping up too quickly after that. Same boots as past few years. Never use trekking poles outside the Alps, and now only used them on some of my recovery walks (just the downhills usually). Legs may be stronger in different muscles through increased cycling in lockdown, as it's a low-impact activity and doesn't need leg stability like hiking does. Always had my home working desk/chair set up properly. None of my shoes are wearing unevenly.

I thought it'd be back to normal by now, it's been 5 months since that first painful hike and 4 months since the really bad one when I hobbled back to the car. I've been doing the leg exercises, applying ice, and taking walks daily without fail since I found the problem. Unfortunately I live in a city in a flat part of the country, otherwise I'd hike daily if it helped. I'm staying away from gyms (never been in years) due to the pandemic, sticking to the at-home exercises I've been given.

Thanks in advance for your stories and wisdom.

[NickyRannoch]

Good news - the first time it happened to me it took about 7 months on and off to sort itself out but it will pass and you will be back doing activity again.

Bad News - you will always be susceptible to it and ITBS is a nightmare. You can foam roll it and stretch it but my physio says its like trying to stretch a lorry tire. Its so dense and tight there's only so much you can do.

What I have found is you can't stop/start exercise. In summer months when I'm never off the hills or just walking round the park after work I never get a bit of bother. Its in winter when you can't be bothered with those post work walks in the cold and rain but you still want to do 12 miles on a Saturday where problems start.

Almost all my injuries are March/April When you have big upswing in activity levels.

All that said, when you actually have pain, there is a lot to be said for having a complete rest for 3 or 4 days ie no walks, no stretches, lots of icing etc

[WalkWithWallace]

I'm always a bit wary of giving advice about medical issues , however having suffered from ITBS myself I really feel your pain.

As a short term fix, I used one of these bands and it worked a treat:

https://www.firstaid4sport.co.uk/mueller-iliotibial-band-itb-strap-black/

However medium to long term, I didn't want to rely on a knee band. I found an osteopath that really worked into the ITBs and ironed them out, he was fantastic, albeit painful. I stopped going and maintain it with foam rolling, stretching and one of those massage guns.

Good luck, I hope you can get on top of it.

[AyrshireAlps]

In the winter I run 5k occasionally to try and keep my fitness up, and do the odd 20 mile flat bike ride. I worked in an office full time, been working from home since lockdown. As part of my commuting and lunch stroll I used to walk 2 miles daily including 300 staircase steps up and same down.

Don't take this the wrong way, but for someone that's 32, that's not very much exercise, I know from experience that wfh, and indeed any office work can lead to being far too sedentary and that's before you even look at the seat you're using and your posture.

I've a friend who started walking a few years back, had horrendous knee problems, bought knee braces, took so much brufen it was affecting her stomach, was at all sorts of physios...

Then she started taking her exercise seriously, doing a lot more in between walking, and has no issues at all any more.

This may not be you, and feel free to tell me to **** off but it's worth thinking about.

I had a knee operation at 38, was told not to run more than 5k by the consultant, which I did (I didn't run at all tbh after that!) but noticed the knee was getting stiffer and stiffer. Started running at 42, 5k's etc at first, then built up to hill races and then managed 5 ultramarathons last year, not a peep out of it now, best thing I ever did for my knee was to start running, the polar opposite of what most of us think!. I now run 20-30 miles a week, depending on how much hillwalking I'm doing.

All the best mate, let us know how you get on.

[UpAndDownMountains]

Good news - the first time it happened to me it took about 7 months on and off to sort itself out but it will pass and you will be back doing activity again.

Bad News - you will always be susceptible to it and ITBS is a nightmare. You can foam roll it and stretch it but my physio says its like trying to stretch a lorry tire. Its so dense and tight there's only so much you can do.

What I have found is you can't stop/start exercise. In summer months when I'm never off the hills or just walking round the park after work I never get a bit of bother. Its in winter when you can't be bothered with those post work walks in the cold and rain but you still want to do 12 miles on a Saturday where problems start.

Almost all my injuries are March/April When you have big upswing in activity levels.

All that said, when you actually have pain, there is a lot to be said for having a complete rest for 3 or 4 days ie no walks, no stretches, lots of icing etc

That's good to hear. Lockdown arrived again before I had time to build my conditioning back up fully. Yes, been getting away with my biomechanical problems unaware so far through being conditioned (despite minimal winter exercise), but will need to be more deliberate with regular exercise as I get older. I have been taking complete breaks from doing anything (except icing) for a few days after pain, I just hope I can get back to the stage where I can do a decent hike every day on a week off work.

I'm always a bit wary of giving advice about medical issues , however having suffered from ITBS myself I really feel your pain.

As a short term fix, I used one of these bands and it worked a treat:

https://www.firstaid4sport.co.uk/mueller-iliotibial-band-itb-strap-black/

However medium to long term, I didn't want to rely on a knee band. I found an osteopath that really worked into the ITBs and ironed them out, he was fantastic, albeit painful. I stopped going and maintain it with foam rolling, stretching and one of those massage guns.

Good luck, I hope you can get on top of it.

Interesting. Just now learnt the difference between a physio and an osteo. My physio has been working the band, at first it was painful but now it's reduced a lot. I might ask him about those bands, not as a solution but to keep in my rucksack in case of an emergency so I don't make it worse by hobbling to the end of the route. I have been wearing knee pads if I'm mountain biking in the forest since early last year, they're comfortable and not tight on the knee like that strap but I hope they've not contributed to kick-starting this problem when hiking. I'm rolling and stretching religiously but I suspect the last two months without proper hilly hiking hasn't helped.

In the winter I run 5k occasionally to try and keep my fitness up, and do the odd 20 mile flat bike ride. I worked in an office full time, been working from home since lockdown. As part of my commuting and lunch stroll I used to walk 2 miles daily including 300 staircase steps up and same down.

Don't take this the wrong way, but for someone that's 32, that's not very much exercise, I know from experience that wfh, and indeed any office work can lead to being far too sedentary and that's before you even look at the seat you're using and your posture.

I've a friend who started walking a few years back, had horrendous knee problems, bought knee braces, took so much brufen it was affecting her stomach, was at all sorts of physios...

Then she started taking her exercise seriously, doing a lot more in between walking, and has no issues at all any more.

This may not be you, and feel free to tell me to **** off but it's worth thinking about.

I had a knee operation at 38, was told not to run more than 5k by the consultant, which I did (I didn't run at all tbh after that!) but noticed the knee was getting stiffer and stiffer. Started running at 42, 5k's etc at first, then built up to hill races and then managed 5 ultramarathons last year, not a peep out of it now, best thing I ever did for my knee was to start running, the polar opposite of what most of us think!. I now run 20-30 miles a week, depending on how much hillwalking I'm doing.

All the best mate, let us know how you get on.

Not at all, I am indeed pretty inactive during the winter and am aware of the problems of sedentary lifestyle (it's even worse working from home). I just tend not to get out for proper hikes due to the weather, daylight, and distance from the city. Basically I like walking proper mountains and being able to see nice scenery, without those I'm not motivated (well, I am now - to avoid this problem I have). I'm going to have to change something about this. Summer I'll be hiking pretty much every nice weekend, long weekend, or week off I get. I didn't mention it but I do basic bodyweight fitness 2-3 times a week. Good to hear it worked out for you (colleague has a similar story), I'm currently on "no running" by my physio.

Can anyone recommend any exercises for hiking that can be done reasonably close to my city home in a flat area? I know there's no substitute for real rough hilly continuous up then continuous down terrain. So far I've been doing long path walks, sessioning small slopes and sets of stairs, and doing those in hiking boots while carrying a normal weight rucksack. Plus the specific leg exercises like squats and step up/down with a chair. If only someone made a downhill treadmill with a rocky belt on it...

[AyrshireAlps]

Phew, after I read that back to myself I realised it sounded awfy condescending, sorry, never meant to!.

If you have access to kettle bells or dumbbells, weighted lunges and squats basically recreate the hill walking action, and are great for core stability.

[simon-b]

You say you suffer over pronation of the feet. Has your physio suggested any exercises to strengthen your feet? The whole kinetic chain is linked, and as you're finding out, a misalignment in one place can set off postural issues up and down the whole skeleton. I find my right foot tends to pronate more than my left, and supportive insoles helped temporarily during any problem phases. But in the long run, I've found strengthening the feet then returning to more normal insoles seems to be working. Exercises with a small massage ball, eg picking up the ball with your toes, could be an idea.

[WalkWithWallace]

Useful video here:

[simon-b]

Useful video here:

Agreed. Sounds like excellent advice from someone who knows what he's talking about.

[UpAndDownMountains]

Thanks for sharing. Loads of useful training content on his channel.

[thand]

Good luck getting this sorted.

I have suffered with the IT band on my right knee on and off for a few years. Last few years I've not had any issues despite increased milahe for running. I wold say everyone's experience and cure is different so dn;t give up on it:

1. Went to an NHS physio. Got told instability in my core and pronation causing it. Got the NHS stretches sheet. Didn't work

2. Found a private sports focussed physio. He was more focussed on weakness in my left leg causing compensation in my right leg which was causing the IT band pain in my right knee. Was focussed more on evening out the legs with weight training and isolation exercises. So lots of squats,deadlifts and single leg squats as well as stretches like "one legged pigeon" etc to open up the hips.

3. I carried this on and now do a wieght session every week, youtube yoga twice a week (about 20mins - can recomend Adrienne). I also found that switching from pronation control running shoes to neutral running shoes has helped (despite being a pronator - apparently so is Mo farah).

4. I also try and make sure I run more consistently with no large increases in weekly distance.

No issues in over two years.

Hope you get it sorted

[UpAndDownMountains]

I'm delighted to have done a decent weekend of hiking including 2500m of descent, without any pain.

As recent as April, I was beginning to get pain after just 100m of descent.

I've been following an online "Mountain Proof Knees" course by Chase Mountains (creator of the video @WalkWithWallace posted), seems to have done the trick. I've not even finished it yet. Lots of strength and mobility exercises.