In an ongoing dialogue (verbal & written) about the role of a robust exercise routine for health and longevity, this blog is a follow-up to a previous blog I wrote about iliotibial band syndrome: What is it, and how is it rehabilitated? I chose this injury to blog about because it pulls in various aspects of physical health. Before I get to this specific case, indulge me in letting me elaborate on what I mean when I state that it “pulls in various aspects of physical health”. By nature, we want things to be simple. So, when your knee hurts, it’s human nature to want a simple knee pain-relieving solution. As such, pain medication is often the first thing we’ll try. Take a pill, the pain goes away, problem is solved. Or is it? Firstly, if the pain does go away, great! But, we’re still left with the unanswered question as to why the knee hurt in the first place. Some will ask this question, while others will not. Those who ask might then take the next step and book a chiropractic visit with me in Toronto, whereby I will then attempt to answer the not-always-simple question: Why do you hurt?

So, Why Do You Hurt?

In the case of lateral knee pain, various diagnoses could explain the pain. Each person will have a history that helps narrow the list. For instance, knee pain following a traumatic injury will have a different set of differential diagnoses compared to the gradual/insidious onset of pain. When there is trauma (eg. twisted knee playing soccer, falling while skiing), imaging, such as an X-ray or ultrasound or MRI, may be required. In the absence of trauma, I start to think about the biomechanics of the individual. But, I cannot just consider the biomechanics of the knee. Non-traumatic knee pain is often influenced by the biomechanics of the anatomy above and below the area of pain: Hip and ankle.

Are the joints healthy?

{What is a healthy joint? A healthy joint moves through its entire range of motion with ease and good motor control. Anything less than this qualifies as a degenerative joint that may be influencing itself and the rest of the body.} Are the muscles around the joint healthy? {What is a healthy muscle? A healthy muscle is void of strains/tears and is strong and flexible (enough) to help the joint move properly and last a lifetime.}

Highlighted Point: Exercising regularly is essential to helping your body maintain itself for a lifetime. But, the word ‘exercise’ is vague. Various forms of exercise have unique impacts on the body. We will delve deeper into this in future blogs, but you can break exercise down into a handful of categories:

• Strength Training
• Cardiovascular / Respiratory / Metabolic Training
• Mobility Training
• Stability Training

So, keeping in mind that any pain may have biomechanical factors at the site of pain, above and/or below the site of pain, not to mention other factors, such as non-physical factors (i.e. psychosocial factors), let’s get to this case study:

Case Study: Iliotibial Band Syndrome

In late November 2023, a 70-year-old patient of mine presented with intense hip pain (pain on the outside/lateral side of the hip). This patient is a highly active, strong man who has engaged in strength training throughout his life. During his chiropractic appointment, he had been complaining of left-sided back pain at times throughout the year, but never with this level of intensity. After a re-evaluation, I diagnosed this gentleman with hip pain due to muscular tension of his left quadratus lumborum (low back muscle) and lateral hip musculature (gluteus medius and tensor fascia lata/TFL). I treated these muscles with laser therapy, and soft tissue therapy, and prescribed various stretches and strength training exercises for his hip muscles.

Highlighted Point:

He was so flabbergasted that I suggested his lateral hip muscles were weak since he’s been exercising his whole life. Surely a lifetime of exercise would prevent muscles from being weak?! We spent a lot of time together discussing the matter, leading to a review of his exercise routine. Sure enough, we found various holes in his exercise routine, including the following:

• Not enough stretching. Period.
• No mobility training.
• Not enough cardiovascular training.
• Certain muscle groups were not being strength-trained, including the aforementioned lateral hip muscles.

I sent him home to do his self-care and asked him to return in 2 weeks. He returned, still in pain, and now had significant stiffness in the mornings and intense lateral knee pain.  Clearly (to me), his injury had evolved into iliotibial band syndrome (ITB syndrome).

I continued to treat the injury, per my approach outlined in the previous blog about ITB syndrome.

Treatment included:

• Laser Therapy to the lateral hip muscles, ITB, and lateral knee
• Functional Release (i.e. soft tissue therapy) to all relevant muscles
• Joint mobilization of his spine, hip, and knee
• Practiced and prescribed strength training for Glutes, TFL
• Practiced and prescribed Joint mobility exercises for the spine, hip, and knee
• Practiced and prescribed various stretches for the spine and hip/knee muscles

A few visits in quick succession (4 treatments in 2 weeks) before the Christmas holidays helped this gentleman begin to recover. At first, the pain persisted and he developed significant pain in the mornings, upon waking, but noticed the pain improved as the day progressed. But, throughout the Christmas holidays, the pain (albeit much less) was still present. At my suggestion, due to my holiday absence, he consulted with my physiotherapy colleague. By and large, my colleague agreed with the diagnosis and treatment plan, encouraging the patient to stay consistent with the exercises. One difference in the management of the case was the recommendation to get X-rays to assess for arthritis of the hip and spine.

Highlighted Point:

I had previously assessed this gentleman’s hip joint and had concluded that I did NOT suspect arthritis of the hip to be a key component of this injury/pain. However, when pain persists, it is certainly a reasonable recommendation to get some form of imaging to rule out any sinister cause of the pain. As it turns out, I was correct on two fronts: First, the hip did not show any significant signs of osteoarthritis. Secondly, as previously suggested throughout the year, I suspected his lumbar spine was arthritic and would likely be playing a role in the development of this hip injury. Sure enough, x-rays revealed some significant spine arthritis and some scoliosis, explaining the role of the tight QL muscle.

Back from holidays, I met with this patient during the first week of January. Thankfully, he had turned a corner and was feeling much better. He was sleeping better, no longer waking up with pain and stiffness, and was moving with much more ease. He wasn’t 100%, as he was having some compensation tension/discomfort in his quadriceps, but certainly relieved that the worst was over.

Silver Lining:

Injuries and pain suck. But, if we learn from them, improve our exercise routine, and get the care we need (and deserve), we can recover and often be better off for it in the future. Recovery doesn’t always happen as fast as we’d like, especially when we’re older, but stick to the recipe and positive results can be expected.  In this case, a classic case of ITB Syndrome, this 70-year-old gentleman who “worked out” his whole life, has not only recovered but has cultivated a much more robust exercise and self-care routine, which includes:

• Full Body Strength Training (not just his “favourite” exercises)
• Mobility & Flexibility Routine
• Physical Treatment, including chiropractic care with yours truly