The Clinic.

ILIOTIBIAL BAND SYNDROME

I was a high school track athlete until about a year ago when I developed severe pain on the outside of my left knee during a run. I had worked up to a schedule of five miles a day, six days a week when this pain began. I have seen doctors who made the diagnosis of iliotibial band syndrome and prescribed stretches, ice, and rest for six weeks. The problem did not improve and I had an MRI and a series of two cortisone injections. The MRI was normal. Now I'm swimming, water running, and going to a physical therapist, but so far, I haven't noticed any improvement. Do you have any suggestions for me? I would really like to get running again--track is the sport I love.

Kelli Peterman

Uhrichsville, OH

Iliotibial band syndrome is a common affliction of young runners, as well as adult long distance runners. The iliotibial band (ITB) is a thickening of tissue connecting the side of your thighbone (femur) to the area just across your knee joint. The syndrome describes pain that occurs during running, and is due to a chronic inflammation of the soft tissue where the end of the femur meets the knee. As the knee joint bends and extends, this tissue may rub against the flared end of the femur, causing inflammation and pain. This is more likely to occur if the tissue is thickened or tight, if you have flat feet, worn running shoes, bowed legs, do lots of downhill running, run regularly on banked surfaces, or have a previous injury to the area.

ITB syndrome usually causes a slowly building, intense dull pain during running, which recedes when you stop. Others report a more sudden onset of a sharper pain, as you have experienced. As is always the case, other causes of lateral knee pain need to be ruled out. A lateral meniscus tear, a loose piece of bone or tissue in the joint, or a severe popliteus tendon injury can usually be found on MRI, which is normal in your case.

However, MRIs have their limits, and mild injuries, especially lateral ligament and tendon strains may be missed. Physical examination is very important. Assuming your diagnosis is correct, standard treatment for ITB syndrome is as follows:

* Temporarily STOP running. You should not try to run through this problem.

* Initial icing and wrapping.

* Non-steroidal anti-inflammatory medications like ibuprofen and others can be useful, not only to control pain temporarily but also to reduce inflammation.

* ITB side stretching. While standing, with the hand opposite the injured leg against the wall, place your injured leg crossed behind the other leg. Lean away from the injured side into the wall, pushing the hip on the injured side in the opposite direction. Keep your feet anchored and bend the uninjured knee as you stretch. You should feel the stretch from the outside of your hip to the knee area. Hold each stretch for a count often, and repeat five times, each time with controlled breathing and an effort to make this a relaxed stretch. Do not overdue this or stretch past the point of pain.

* Physical therapy is effective if it is used as an educational process. You should listen, learn, and apply the principles to your running program.

* Return to full running should be very GRADUAL and always within discomfort-free limits. This is extremely important.

* You must identify and correct the causative factors in order to return to running without a return of the pain. Avoid banked surfaces, get a professional fit for running shoes and let the salesperson know of your injury. Replace your shoes frequently. Any other biomechanical issues such as hyperpronation or leg length discrepancies, should be evaluated and corrected with orthotics if necessary.

* I recommend cross training with non-aggravating activities while you are rehabilitating. These could include swimming, pool running, bicycling, or any other activity that does not aggravate the condition.

* You will need patience. ITB syndrome can be hard to resolve, but with patience, you will be running again.

Rob Scott, M.D.

San Diego, CA

EATING FOR THE BIG RACE

I'm getting ready to run a marathon. I've trained well and I'm as ready as I'll ever be. I have focused on training and diet leading up to the race and I realize that as the date approaches, I don't have a clue what to eat on race day. I really want to do my best and I'm sure that for a 26.2-mile run, what I eat the day of the race must make a big difference. Can you give me some advice?

Don Rabinson, M.D.

Bainbridge, GA

You are so right. What you eat before the race can make a huge difference. First, just to clarify what you already know, leading up to the race, you should emphasize carbohydrates--about eight to ten grams of carbohydrate per kilogram of bodyweight. Just before the race, after a good night's sleep, your liver is depleted of the carbohydrate (glycogen) it needs to maintain blood sugar levels during your run. Breakfast is essential. The current advice is to base the amount of carbohydrate in your pre-event meal on your body weight. You should try to consume two grams of carbohydrate for every kilogram of body weight, two hours before the start of the marathon. To calculate your weight in kilograms, divide your weight in pounds by 2.2. If, for example, you weigh 150 pounds, 68 kilograms times two would be 136 grams of carbohydrate in your pre-event meal.

If you can eat three hours before the race, you can increase to three grams of carbohydrate for each kilogram of body weight, and that should probably depend on your pace. The longer your marathon will take, the closer your meal should be to the time of the run. If you are a four-hour marathoner, you should not eat more than two hours before the race. If you run at two-and-a-half-hour pace, increasing the time before the race and the amount of carbohydrate would be reasonable.

Here's what a 136-gram pre-event breakfast would look like (the right column is grams of carbohydrate):

1 bagel (4 oz.) 60
1 rounded tablespoon jam 20
8 oz. orange juice 30.
1 small banana 20
4 oz. milk      6

Nancy Clark, R.D., MS.,

Brookline, MA

In general, eat two to three hours before an event if at all possible. Eat whatever and however much you are comfortable eating. The bottom line is to try out foods and times before the big event and do not try something new on the day of the race. Experience will help you establish what your body will tolerate.

Sarah Harding Laidlaw, M.S., R.D.

Glade Park, CO

RUN MORE MARATHONS?

I am 67 years old and recently finished the Cowtown Marathon in five hours even. This was my second marathon--I ran the same one last year and finished it in almost the same time. It seemed like an awful lot of training for a once-a-year run. What I have been thinking about is running four marathons a year with approximately three months between each one. This makes more sense to me as I can stay in good shape between the marathons, and it won't be such a strain as doing it once a year.

Does this seem like a reasonable strategy for a man of my age? Between the marathons would it be best to do a long run every other weekend or every third weekend? What distance would you recommend for the long runs?

Wes Collins

Your strategy for running more than one marathon per year is reasonable. Three marathons would be better than four, which might allow for better recovery, tapering, and training between events.

Doing a long run every other weekend would make you stronger. However, monitor your recovery. It may take you two weeks to recover from a long run. Vary your long runs according to their position in your taper or build-up. Your standard long run should be in the neighborhood of 18 to 20 miles, but that distance can increase somewhat three to, four weeks before the marathon. Long runs on recovery weekends could be between 10 and 13 miles. These runs could be shorter if necessary.

Lee Fidler Ed.S.

Stone Mountain, GA

Running two marathons in one year is enough for most runners, while some might be able to get through three with reasonable results. At 67, why risk injury, staleness, or overtraining? How about setting different goals for yourself, like knocking some time off your marathons?

Bob Clover

Sleepy Hollow, NY

ARE YOU BOTHERED BY AN INJURY? DO YOU HAVE A TRAINING OR DIET QUESTION?

Ask The Clinic. In care of The American Running Association. 4405 East West Highway, Suite 405. Bethesda, MD 20824. FAX [phone]. or e-mail at [e-mail]. Write a letter Including as much relevant information as possible about you (age, weight, etc.) and your injury (type and location of pain), training schedule (typical weekly workouts, pace, surface), athletic and medical history Sole wear, recent changes In training. etc. Type or print your letters. Hand-written FAXed letters cannot be accepted. All letters, even e-mail, must include your name, address and phone number. Responses usually take three to four weeks, but can take as long as five.