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A tale of two kinds of knee pain

 •  • by Paul Ingraham
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These are MRI images of a knee in severe pain after a marathon (originally shared by Dr. James Noake, with consent). The inflammation is dramatic (the bright white areas). The kneecap position is nutty.

A mair of MRI images of a knee, one straight on, the other top-down.

Both images show “very impressive IT band inflammation” — the very prominent white area indicating strong inflammation on the side of the knee over & above the lateral epicondyle, but also spreading anteriorly all the way to the edge of the kneecap… which very clearly — which obviously sitting much further out to the side than it should be, almost out of its groove. The image is via Dr. James Noake & has been used with consent.

Pictures like this certainly tell some kind of story about the relationship between iliotibial band syndrome and patellofemoral pain, the two most common kinds of runner’s knee. Unfortunately, we don’t know exactly which story…

  1. Is it the one where iliotibial band syndrome and patellofemoral syndrome actually cause each other?

  2. Or is it the one where they are “simply both common overload conditions rearing their heads simultaneously?”

Both are possible!

Either way, the signs and symptoms of both conditions co-exist so dramatically here that it’s hard not to wonder if they are locked into some kind of vicious cycle together, perhaps through the shared mechanism of tight lateral connective tissue and muscle: basically, a tight IT band and terrible patellar tracking working together to cause both kinds of pain. It is possible.

Or maybe every sign and symptom here — including that wonky patellar position — is simply a reaction to overload of otherwise normal biomechanics.

Many professionals responded to Dr. Noake’s post, but none ventured a strong opinion about the order of chickens and eggs. For what it’s worth, the patellofemoral pain did come first (not the displacement, that’s just unknown). It started with pain behind the outside edge of the kneecap, but then spread, and soon the case was dominated by severe lateral knee pain, typical of a nasty case of ITBS, and that’s where the lion’s share of inflammation is on the post-marathon images.

I have huge e-books about both of these conditions, both providing much greater detail than you can find in any professional guide published in a medical journal (and more fun to read to boot). You can buy them both from me directly — see my store. Or get one for free for the next three days! The patellofemoral pain book is a free bonus right now when you sign-up for a trial of Physio Network’s membership program.