Between 25 and 42% of all overuse injuries related to running occur in the knee, making it one of the most commonly injured areas. Among runners, Iliotibial Band Syndrome (ITBS) is the second most common injury and is the most common reason for lateral knee pain. Women are twice as likely to develop Iliotibial Band Syndrome as men are and it can be a problem for everyone from adolescent to senior runners.
Probably every runner knows that the side of the thigh can be an extremely painful place to hit with the foam roller. Iliotibial Band Syndrome is often described as a burning pain in the lower lateral aspect of the thigh and is fairly easy to diagnose on examination. However, Iliotibial Band Syndrome can be a multifactorial problem that is typically not easy to cure for most runners and their clinicians.
Contraction of certain muscles causes the iliotibial band (ITB) to separate the knees from each other (abduction). It restricts adduction of the hip (bringing the knees together) and it also checks inward twisting of the knee. When standing on one leg, the ITB stabilizes the lateral aspect of the hip and knee and during the gait cycle, it stabilizes the entire lower leg while the other leg is swinging through by utilizing compression at the knee.
For years, it was thought that Iliotibial Band Syndrome was caused by the ITB repeatedly snapping over the lateral part of the femur and causing irritation of a bursa. It is now been proven that this forward and backward “movement” of the ITB is an illusion created by the fact that the tension changes front to back in the IT band depending on whether the tensor fascia latae or the gluteus maximus is contracting more. (The image above was provided by Thomas C. Michaud from his book Human Locomotion and used with permission.) Underneath the ITB at the knee, there is fat tissue that has a large amount of nerves and blood vessels and can become compressed and painful. The pain from Iliotibial Band Syndrome can occur from repeated compression of this fatty tissue or from the actual damage to the ITB. When it is from repeated stress to the ITB, it acts like a tendinitis.
Damage to the ITB can occur from body positions that cause increased hip adduction and knee internal rotation. Increased tension and strain, torsional strain or both may cause injury to the ITB, especially over the course of many miles.
It is extremely common to find that people who have Iliotibial Band Syndrome also have a narrow gait stance or a crossover gait. A crossover gait is when the front foot crosses the midline of the body in the line of progression. This type of gait has the tendency to increase pronation, pronation velocity and excursion of the tibia. The picture below is an example of crossover gait.
Just like any overuse injury, Iliotibial Band Syndrome is preventable. Because Iliotibial Band Syndrome is an overuse injury, rest and activity modification will greatly contribute to recovery. Taking time off from running can be extremely beneficial to helping you recover, but I realize that many runners will not heed this advice. Even with rest and modifying activities, you are not actually addressing the problem directly and there is a high probability that the problem will come back after a person resumes their normal running volume.
Iliotibial Band Syndrome can be caused by many different problems and is usually related to dysfunction in the hip or ankle. The men who get it have different biomechanics than women. It could be caused by too much pronation in the foot or in feet that supinate too much, which are opposite problems. The complexity associated with Iliotibial Band Syndrome means that you often need a proper examination by a qualified healthcare professional.
Some studies indicate that a low percentage of certain lower extremity overuse injuries can be prevented with custom foot orthotics. These should not be shock absorbing insoles but should be contoured to the bottom of the foot to help control motion.
Anyone suffering from Iliotibial Band Syndrome should be evaluated for the amount of hip adduction and relative internal rotation of the knee during running and walking gait. Presence of weak abductors should be noted as well as whether the person has rear foot eversion. Any subsequent intervention for the person should be based on whether these factors are present.
Overuse injuries are related to multiple different factors in a person’s training including dosage/volume, technique, strength/fatigue, asymmetries of movement or anatomy, activation patterns and neurological demands. Major problems in any of these areas can lead to problems and cause overuse injuries, so making sure that you get help if you develop a problem is key.
One thing that can be used to assess a person that has had a lower extremity injury is a single leg hop test. This group of tests can be used with a variety of lower extremity conditions to determine if the person is ready to return to their sport. There may be major differences in performance from side to side due to problems with strength, range of motion or problems controlling posture. For more information on this test, look at https://harmonychiro.com/hop-test to watch a video.
The flexibility of the hip abductors is important because shortness in the TFL, gluteus medius or gluteus maximus muscles can cause excess strain on the ITB. Soft tissue treatment, like Graston Technique, should be directed at tight muscles and the involved regions. You can attempt to do some of this work with foam rolling and other kinds of self-myofascial release, but make sure that you get help if the Iliotibial Band Syndrome persists. This type of treatment should be followed up with stretching to both the gluteus maximus and TFL. Stretching the hip abductors can be one of the most challenging stretches to get right on your own so seek help if needed.
Endurance is one of the first things that needs to be built up in the muscles and then muscle strength can be increased. Working on the abductors of the hip is important and the gluteus medius muscle is the most important of these to rehab. After the hip abductors have developed some endurance, strength should become a focus to allow continued progression and recovery.
The tensor fascia latae muscle does have the tendency to be overactive and tight so strengthening it would not be a wise move. A study showed that hip abductor exercises completely resolved symptoms in over 90% of the runners studied.
Because internal rotation of the knee is implicated in developing Iliotibial Band Syndrome, strengthening the external rotators of the hip can help to maintain control of the hip preventing internal rotation of the knee the yanking of the ITB.
For ideas on how to strengthen the hip abductors and the glutes, take a look at my sports medicine blog at https://harmonychiro.com/blog/ as there are several different posts to give you information.
In people that have a narrow stance or step-width that does not crossover, widening the distance between your feet by a little over 3 inches may be able to reduce tissue loads to allow things to heal properly. Widening the step width has the tendency to reduce both hip adduction and knee internal rotation.
Gait retraining after strengthening to be sure you have adequate step-width may be extremely effective in treating Iliotibial Band Syndrome. You can try to widen your stance by running over road markings (watch out for traffic or try it in a parking lot) and trying to not let your feet touch the line.
As always, make an appointment with a qualified healthcare practitioner if you have difficulty with Iliotibial Band Syndrome.
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