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runners knee

Health, physical therapy, physiotherapy

Therapeutic Ultrasound – Why is it still used?

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With therapeutic ultrasound not having a definite mechanism of action on injuries and having no significant evidence behind it  – I ask why ultrasound is still used so much as a treatment for musculoskeletal injuries?

Too often when treating in the clinic I am asked either “do you use ultrasound”, “why don’t you use ultrasound” or “normally my past physio just used ultrasound and a heat pack…”

Now I know everything has its place and its uses but when there are so much better alternatives than therapeutic ultrasound that do actually help more that placebo – why not use them?

Now, here is a little background info on ultrasound:

ultrasoundtherapyWhat it is: Therapeutic ultrasound (US) is a popular electrophysical treatment method that generates mechanical energy which propagates through tissues (1). Among physiotherapists, it is used to treat soft tissue injuries, accelerate the wound’s repair, augment fracture healing, on swellings resolution and to solve some bone and circulatory injuries.

Although many lab‐based studies have demonstrated a number of physiological effects of ultrasound upon living tissue, there is remarkably little evidence for real effect and benefit in the treatment of soft tissue injuries(2).

How much is it used?

Therapeutic US is still used almost daily throughout many countries as a go-to treatment for acute injuries and overuse injuries such as runners knee.

  • In Australia, it is used DAILY by 84% of health professionals
  • in England, it is used in 54% of all interventions in private clinics(1)

There are some countries which are ahead of the game with such as Sweden, where it is used less than 5% of the time and this needs to be followed by other developed countries(3).

EBP triadWhat’s the evidence then?

In most studies, therapeutic ultrasound proved to be no better than Placebo for a wide range of musculoskeletal conditions (4,5), and that there is a lot of variation in parameters used.

I could go into detail but the main point is, therapeutic US has been shown to be no better than placebo or exercises(6), so why would a therapist waste ten minutes of treatment time when they could be doing something else?

Evidence-based practice is becoming increasingly important in physiotherapy as we want to use what works for our patients – So why is US use still so rife in the profession? Is it lack of motivation, education or just plain lazy?

Let me know your thoughts!


Extra reading:

Paul Ingrahams post in a similar vein is a great read


Health, Knee pain, running

IT Band Syndrome: Heal Fast and Strong

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Are you sick of trying to fix your IT Band Syndrome by stretching, strengthening or foam rolling your Iliotibial Band?

Good news!

You don’t need to waste your time with that any more. Here you will find a clear summary of what really causes IT Band Syndrome and what you can do to really help it. All based, as always, on current research and good old-fashioned experience from a runner and physiotherapist to help you heal strong and fast.

What is IT Band Syndrome really?

IT Band Syndrome is a common overuse injury in runners and cyclists and is commonly thought of as a friction syndrome.

First of all, the one myth that needs to be sorted out is this:

IT Band Syndrome is caused by friction, from the IT Band rubbing over the lateral knee


Recent evidence shows that it is not due to friction and that there are some easy treatments and exercises that can effectively treat it.

In actual fact, IT Band Syndrome is caused by compression of the IT Band. Lets have a quick look at the anatomy so that you can see why this is:

How IT Band Syndrome happen then?

IT Band SyndromeThe IT Band is a thick tract of connective tissue which connects up your hip muscles to the knee and helps stabilize the knee in the process. It originates from the Gluteus Maximus and Tensor Fascia Latae muscle (see in the image to the right) and ends up attaching into the tibia (right up the top of your shin bone).

Before attaching into your tibia, the IT Band crosses over the lateral femoral epicondyle (where IT Band Syndrome pain is felt). For years it was thought that the IT band slid back and forth over this epicondyle as your moved your knee (and this is still far too popular theory: 1,2,3). Fortunately it has been proven through studying cadavers and use of MRI that the IT Band is actually anchored to the femur by fibrous strands and so cannot actually slide – so, no friction. The MRI’s also showed that at this point, underneath the IT Band is a layer of fat, full of little nerves and blood vessels, making it very sensitive, especially when compressed.

So from this, based on anatomical findings at least (which are hard to argue with) IT Band Syndrome is associated with compression of the sensitive layer of fat beneath the IT Band rather that friction.(4) This knowledge of the IT Band and it’s attachments isn’t all that new but has unfortunately been overlooked and ignored for too long. A big driver behind the myth of ITB friction syndrome is the perception that movement of the ITB across the epicondyle can be felt, but this is an illusion because of changing tension in its anterior and posterior fibres.(5)

Risk Factors for IT BAnd Syndrome

ITB syndrome is a repetitive strain injury caused by the IT Band compressing the layer of fat beneath it. The factors leading to this happening are thought to be:

  • Increased hip adduction (the leg moving inwards, towards the opposite leg)
  • Increased knee internal rotation (7)
  • Impaired function of the hip muscles
  • Poor running technique

The good thing is, if these biochemical issues are found and addressed, a resolution can be found.(6)

So, here is how you should go about treating your IT Band Syndrome the right way.


1. Get a biomechanical assessment done by a sports physio or similarly qualified health professional. This should look at the strength, control and endurance of your hips, whether your have hip drop etc. They should also check out your technique.

Tip: As well as this, you can do a quick test at home to see where you are weak – See this post to find out how easy it is.

2. Start your rehab exercises that you can find detailed on a past blog post here

3. Make sure that your running technique is spot on – Your physio can help with this, or check out this post for some easy tips.

4. Shoes: Make sure that you shoes aren’t too old and worn and ensure that you do not drastically change shoe style. For example, don’t go from a cushioned, controlling runner to a minimal Nike or Vibram all of a sudden – it needs to be gradual.


Lastly, feel free to comment below and please share if this has helped you.


Health, Knee pain

How to Prevent ITB syndrome: IT band exercises

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ITB syndrome can be painful and difficult to treat, BUT with the right pre-hab and IT band exercises, YOU don’t have to worry about any of that!

Prevention = Cure!

ITB syndrome is all too common, with up to 12% of long distance runners affected and a huge 22% of US marine recruits suffering from this, it is a very, very important problem to not only treat right but prevent. This leads to less time out from sport, training and work  – and more time doing what you love!(1,2)

So to prevent this, we need to sort out the risk factors – lessening the chances of you having to take time out.

For more information on how ITB syndrome happens and the latest and greatest treatments, see our recent post here

The main risk factors are:

  • Downhill running(4)
  • Weak or inhibited lateral gluteal muscles (you hip stabilisers e.g.Gluteus medius)
  • Running around a track a lot in one direction
  • And greater than normal weekly mileage(3)

Now from that you can likely see that three of those points are easy to sort out. You can decrease downhill running and vary up your training more. you can run in both directions around a track, if you run n one. And you can make sure you don’t increase your training miles by more than 10% per week – No problem.

But having weak lateral hips – That’s something we really need to work at.

When your hip stabilisers don’t fire up or are weak, this leads to poor control of your pelvis ad hip abduction. Because of this, other muscles have to compensate for this deficit, leading to tight muscles and poor hip extension. This is a big problem, particularly in runners and studies have shown that runners with ITB syndrome do have weaker abductors in the affected leg.(5)

ITB syndromeOne of the muscles that takes over is your tensor fascia latae (TFL) – meaning it is working harder, often leading to spasm and tension. The clincher is that your TFL attaches into your ITB – That means if TFL tightens up, this tensions the band, making it tighter and tighter – causing compression at the knee and pain for you.



So here is the IT band exercises that we need to do:

  • Strengthen your lateral hip muscles
  • Improve glut activation
  • Loosen off and stretch compensatory muscles – e.g. TFL


The following exercises will do this and put you well on your way to being injury free!

1. Side plank

side plank for core strengthening


Level 1: Rise up into the position shown and hold for 30 seconds. Each time hold it for a little longer so that eventually you can hold it for two minutes.

Level 2: When you can easily hold it for two minutes, try doing side plank leg raises. This is where you rise into the side plank and then lift your top leg straight up and down. Begin this with 3 sets of 5 repetitions and build up, until you can do your goal of 30 in a row! (easily)

Note: If level one is too hard – bend your knees, so that you are lifting off your elbow and knee.

The side plank is great to getting your lateral gluts firing together with your obliques – just make sure you do not stick your bum out – bring it forward so that your body is straight.

2. Donkey kicks

Donkey kicks improve glut activation

Start on your hands and knee as shown and kick your leg out behind your slightly up towards the roof.

Perform 3 sets of 8 reps.

Note: to make this harder your can be on your toes instead of your knees on place your elbows on a gym ball.



3. TFL myofascial release

tensor fascia latae and itb myofascial releaseasis anterior super iliac spineThe TFL is, as you can see the image below a little muscle at the side of your hip. to find it, place your fingers on your ASIS which are the bones on either side of your pelvis at the front. From the side of these, drop down a couple of inches and you should be right on it!

I want you to lie on your side and place a ball under your TFL – you can use any ball you like, massage ball, lacrosse ball, tennis or golf ball. Then slowly roll the ball around that area, working out all the knots and tight spots – this can take 2-5 minutes but is well worth your time!

And remember, a bit of trigger point pain is expected here.


Interesting note for runners: Having a higher cadence (quicker strides) has been shown to lower the risk of ITB syndrome. This is because when you increase your cadence (which should ideally be 180 steps per minute) your land with your knee bent more and your foot below your knee – decreasing the force through the knee and making for more economical running.(5) This also links in with downhill running being a risk factor – when running downhill we land with our legs much straighter a position, placing a lot more force on our knees and hips.


And remember. You are much better off-putting in a little bit of time now that spending a lot of time AND money when you do get injured.

Invest in  yourself


Knee pain, running

Patellofemoral Pain Syndrome: Home rehab and exercises

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patellofemoral pain knee cap pain exercisesCommon names for Patellofemoral Pain Syndrome (PFPS) are Chondromalacia patella, anterior knee pain, runners knee, patellofemoral tracking disorder.

*Now just a quick clarification: Chondromalacia Patella is not PFPS. Chondromalacia Patella is commonly over diagnosed and is when the articular cartilage on the undersurface of your knee cap is damaged. The prevalence of this is far less than Patellofemoral pain syndrome but generally occurs if PFPS is left too long as the cartilage gradually softens and degenerates. This can be confirmed with an MRI. The below rehab exercises and advice for Patellofemoral pain WILL HELP this also, it will just be a longer recovery period.

Patellofemoral pain syndrome. self treatment and rehab at home to decrease pain and get you back to it!What: Patellofemoral pain is felt at the front of the knee and typically comes on gradually typically comes on gradually. Normally the patella (your knee cap) glides in a groove in your femur when bending your knee. It is believed PFPS results from abnormal Patella tracking (not gliding smoothly in the groove) causing excessive compression on the under surface.

This mal-tracking can be caused by:

  • Quadriceps weakness (particularly poor activation of your VMO/inside quads) causing an imbalance.
  • Excessive knee soft tissue tightness
  • Tight Quads and Iliotibial band
  • An increased quadriceps angle (Q-angle)
  • Hip weakness (particularly Hip abductors and external rotators)
  • Altered foot biomechanics eg. over-pronation

Generally, there is always a combination of these factors causing a significant imbalance of forces on the knee cap, leading it to be pulled to one side (like a tug of war!). It is generally pulled laterally.

Symptoms and signs

  • Anterior knee pain
  • Knee stiffness with prolonged knee flexion eg. sitting in movie or driving.
  • Activity-related pain: Running, squatting, stair climbing (especially going down), kneeling, cycling, swimming breaststroke.
  • Tenderness/pain on compression if the knee cap
  • Crepitations or Grating sensation
  • Giving way
  • Swelling around the knee cap

Risk Factors:

  • Female gender
  • Iliotibial band syndrome (ITB syndrome)
  • Training: Long distance running, training on hard surfaces, hills, stairs

Note: it is important to remember that muscle dysfunction and repetitive loading of the Patellofemoral joint rather than fixed biomechanical factors and the major contributors to PFPS(Baker and Juhn 2000) and so there is a lot that can be done to help.

Prognosis: Depends on co-existing conditions, but poor if causative/aggravating factors and not addressed. If symptoms have been there for over 12 months you will have a poorer prognosis but do lose heart, it can get a lot better, you just need to persevere and stick at it 🙂

Test yourself! To see how stable your hips are.

Self Treatment:


Bridge - increase leg strength, glute activation and decrease back pain.Bridge - increase leg strength, glute activation and decrease back pain. improve your athletic and sporting performance with stronger posterior muscle strength and activation1. Single leg bridges: 

Action: 10 x 3-5 second holds on each leg.

Tip: alternate legs and switch your core on.



Heel raised squat for VMO and glute activation for knee pain

2. Decline mini squats:

This squat is great for VMO (your inner quad) activation but it also increase glute activation. I have used a phone book here just to show that you can use anything at all that is 1-2 inches.

Action: Do not push into pain (if it is sore, don’t go as low), you do not need to go below parallel. Squat like you are going to sit down in a chair and do not let your knees go past your toes.

Perform 3 sets of 12, nice, slow and controlled.

Tip: look up to the top of the wall to help your balance.



Foam roller for ITB syndrome, knee pain

3. Foam roller: These are great. If you haven’t got one, get one! (A reasonably dense Foam Roller preferably)

Roll all the way from the knee to the hip, making sure you do it slowly.

Spend 2 minutes on the side as shown and then 2 minutes on the front/quads.

Tip: try to keep your feet off the ground and DO NOT LET PAIN PUT YOU OFF, it will get easier.



Clam exercise plus - gluteus medius strengthening, pelvic stability, leg strength4. Clams:

Lying on your side as shown. keeping your ankles together, lift your top knee 20cm, then lower down again (don’t drop it!)

Goal = 1 set of 50, if you are doing them right, you will need to build up to this.

Tip: Keep your top elbow down on the ground and hips rolled forward.



Hip flexor and quads stretch to decrease back pain, improve posture. great exercise from a trained Physiotherapist5. Quads stretch:

Hold this stretch for 1 minute.

You may need to put a cushion or towel under the planted knee!

Tip: you do not need to lunge forward, to add more stretch, tuck your bum in under you or put back foot up on something (eg. wall or foam roller).

Note: if this hurts the knee (even with padding) then stop doing it and wait a couple of weeks before building it in.


Do these exercises two times daily.



Other things that may help:

  • Brace: while rehabbing your knee, a brace can help keep you moving, such as a Patella Tracker
  • Orthotics: the use of Orthotics reduces PFPS in the short to medium term and addresses bio-mechanic deficiencies on the foot.
  • Ice: after exercise, after a long day or when there is any pain ice minutes for 10 -15 at a time (no longer).
  • Rest, give it a couple of weeks rest. this gives you a great time to get a head start on the exercises and really start the rehab off well.
  • Altering training: shorter distance, get off hard surfaces, cross-train.
  • footwear: throw out old shoes, stay away from shoes with poor support eg: Flip-Flops, jandals, sandals, slippers.

Often it is not the knees fault all this pain and discomfort happens, so to treat this condition it is important to look above (quads, ITB, hip) and below (foot, calf).

Follow this advice for at least 12 weeks (yes three months, you NEED to be serious about this to decrease the risk of early knee arthritis and ongoing pain.)

If you have any questions feel free to comment below.

Please share, comment, follow and let me know how you get on!


You may also like:

Lower Limb rehab

Glute activation, the missing link

Quick stability and balance test

A good research paper if you want more info on PFPS research

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