Iliotibial Band Syndrome Guide

 

Everything a runner needs to know about Iliotibial Band Syndrome

Iliotibial Band (IT Band) Syndrome is a frustrating source of knee and hip pain for athletes, and is one of the most common causes of lateral knee pain in runners. Knowing what IT Band Syndrome is and how to prevent and treat it can help keep you running and not sitting on the side of the road

SYMPTOMS OF ILIOTIBIAL BAND SYNDROME

What are the symptoms of iliotibial band syndrome?

Iliotibial Band Syndrome and iliotibial band pain can present in several different ways. The most common presentation or complaint is pain at the outside part of the knee. This knee pain often is worse when bending or extending the knee, or during activities such as running or cycling. Usually the pain from a developing Iliotibial Band Syndrome is gradual and intermittent in the initial onset and then becomes more painful, more frequent and more consistent as the irritation and inflammation to the iliotibial band worsens.

Often the pain from IT Band Syndrome  may have a gradual onset during running or cycling or other athletic activities, but then the pain may improve and diminish once the exercise is stopped. In other cases, the pain from iliotibial band syndrome can become progressive and significantly  more severe as more inflammation develops the initial phase of iliotibial band syndrome.

In the more chronic cases of IT Band syndrome, the pain may be present even with daily activities such as walking, or sitting for a prolonged period of time, or walking up and down stairs.

You may also notice areas either around the knee or the lateral hip that are tender to touch. In some cases where the Iliotibial  Band is inflamed or irritated over the greater trochanter of the hip, sleeping  on the affected side may become uncomfortable and painful.

Typically, there is not much swelling in the knee with iliotibial band syndrome. If you are noticing a significant amount of swelling in and around the knee, it is important to see your physician to get a proper evaluation. Other orthopedic conditions may be present such as a torn lateral meniscus (part of the knee cartilage) and may require different treatment and intervention in order to get you back to your sport or activity.

ANATOMY OF THE ILIOTIBIAL BAND

What is the Iliotibial band?

The iliotibial band is a thick layer of fascial tissue along the outer part of the leg that runs from the hip to the knee.

Fascial tissue is a type of connective tissue that is mostly made up of collagen. Fascial tissue’s primarily encloses, stabilizes and surrounds muscles, blood vessels, nerves and internal organs.

Fascia is part of the body’s connective tissue which surrounds not only your muscles, but other structures in the body such as nerves, blood vessels, bones and even your internal organs. Its an often-ignored part of the body’s anatomy, even in medical school, but plays a vital role in the striation and function of the body.

Think of the fascial system as a three-dimensional system that helps maintain the structure, support and form of muscles (the fascial version of a girdle or control-top pantyhose). Fascia tissue provides for the transfer of tension and contraction from one muscle group to another and even provides the necessary structure and scaffolding for tissue repair after an injury.

The hip portion of the iliotibial band begins from the upper edge of the pelvic bone. Muscular attachments from the muscle in the front part of the hip called the tensor fascia lata and in the back from the larger muscles of the buttocks, the gluteus medius and gluteus minor insert to the front and back of the upper part of the iliotibial band

 

iliotibial band anatomy

Figure 1 – Iliotibial band anatomy

 

Anatomical studies have shown that the top of the iliotibial band attaches to the femur just below the greater trochanter and the lower part of the iliotibial band attaches to the outside part of the knee lateral femoral condyle and lateral tibia.

 

Causes of iliotibial band sydrome

There’s still some controversy on the “true” cause of iliotibial band syndrome and debate about whether muscle weakness found in runners with iliotibial band syndrome and lateral knee pain caused the iliotibal band pain, or did the pain at the IT band end up causing the weakness in the hip muscles.

We do know that weakness in the muscles around the hip and buttocks (gluteus muscles) can cause excessive hip and leg rotation during running, resulting in increased stress on the iliotibial band and the perception of tightness in the iliotibial band. Other factors that are believed to contribute to  IT band syndrome include running on a sloped surface such as the beach or road and excessive pronation or rolling in of the foot.In our experience, most cases of iliotibial band syndrome develop after an increase in running mileage or due to poor biomechanics and underlying muscle imbalances.

Iliotibial band syndrome may be the most common cause of lateral knee pain in runners with some sports medicine researchers reporting the incidence of iliotibial band syndrome in excess of 22% of lower leg injuries  in runners. The sometimes severe knee pain can limit your running and even walking in some cases.

One of the first things I try to figure out with patients suffering from Iliotibial Band Syndrome is exactly how long they have had the condition and if there were any previous injuries that may have predisposed them to developing their iliotibial band problems  in the first place.

For many athletes, there is a prior injury that changes their biomechanics; running gait, cycling position, etc, that then places extra stress and strain on the lower leg and leads to the development of Iliotibial band syndrome.

In some cases, there may be another preceding injury such as an ankle sprain, a low back injury or another injury that changes their running form just enough to lead to another injury.

In other cases, its simply a case of too much, too soon and overtraining.

Or, as I like to think of it, under recovery from their run training.

(Read about the other three mistakes all runners make that can lead to running injuries.)

The reality is that the cause of your iliotibial band pain can be fairly complex, meaning that the pain your feeling is most likely due to muscle imbalances in the hip and back rather than simply a knee problem.

How can I prevent getting Iliotibial Band Syndrome?

Prevention of Iliotibial band syndrome starts with improving strength in the hip and pelvis, avoiding excessive overtraining, allowing for adequate recovery and rest, following a regular stretching and strengthening program and selecting proper running shoes for your running style.

Sure it sounds like a lot, but we have a step-by-step approach that has helped hundreds of fellow runners.

What are the best initial treatments for Iliotibial Band Syndrome?

Initial treatment for the pain from iliotibial band syndrome can start with an ice massage to the painful area for 10 to 15 minutes after workouts when the pain first starts. For acute injuries (less than 2 weeks) anti-inflammatory medications such as ibuprofen (Motrin or Advil) or naproxen (Aleve or Naprosyn) can help with pain and irritation.

In chronic injuries there is less inflammation of the iliotibial band fascial tissue, therefor acetaminophen (Tylenol) may be more appropriate that the anti-inflammatory medications when dealing with the pain.

What about using a foam roller to fix my IT Band?

A foam roller is a great tool to break up scar tissue and help with myofascial release of the leg and thigh. However, remember that that ilotibial band is fascial tissue and is not prone to stretching.

Let me repeat that… you really can not stretch the iliotibial band. If you’ve ever tried to foam roll your IT Band, you probably remember how painfully the experience was.

So the focus of the foam rolling should be on the muscles that attach to the iliotibial band like the the lateral quadriceps (vastus lateralis), the lateral hamstrings of thigh (biceps femoris) and the gluteal muscles of the hip.

 

What if my knee pain isn’t from IT Band Syndrome?

What if you feel that your symptoms don’t entirely match our description of iliotibial band syndrome? In other words, what else could be causing your knee pain?

There are a long list of possible causes of knee pain and if you’re not clear on the cause, then have a sports medicine professional evaluation your knee and determine the correct diagnosis. As you can see below, the potential different diagnosis of pain to the outside part of the knee where the iliotibial band is location is quite lengthy.

Possible other causes of pain to the outside (lateral) part of the knee

    • Lateral meniscus injury
    • Lateral collateral ligament injury
    • Osteoarthritis
    • Tendonitis of the popliteus tendon
    • Tendonitis of the lateral hamstring (biceps femoris) or lateral calf (gastrocnemius)
    • Referred pain from sciatic nerve and lumbar disc herniation
    • Referred pain from peroneal nerve
    • Osteochondritis Dessicans of the lateral femur
    • Patellofemoral Syndrome

What are some IT Band Syndrome stretches?

Stretching of the muscles of the lateral hip (gluteus and tensor fascia lata) that attach to the iliotibial band is an important component of proper rehabilitation if these muscles are tight. Tightness of these muscles can increase the tension across the iliotibial band fascia and create increased friction under the iliotibial band at the knee.

One simple stretch is to stand and cross your injured leg behind your uninjured leg and bend over to touch your toes. A more advanced version of this exercise is to then extend the arms overhead and slowly reach to the opposite side (for the right IT band, extend the arms to the left) and then continue the stretch as the arms reach for the floor. As you perform this exercise, you should feel the stretch in the side and back on the hip. If you experience pain or muscle spasm then reduce the motion during the stretch.

The Cross-over Iliotibial Band Stretch

The seated cross-over Iliotibial band stretch is performed while sitting on the floor with the legs out straight. Bending at the hip and knee, take the injured leg and cross it over the uninjured leg. Twist the upper body towards the injured side to continue the stretch. An alternative method is to slowly extend the knee and leg of the tight IT band to increase the stretch.

The Figure-4 IT Band Stretch

The “Figure-4’ stretch is an exercise that can be done while seated at a desk and one of our favorite exercises for helping with iliotibial band pain.

Seated Figure-4 stretch with leaning forward

While seated, cross the ankle of the injured leg on top of the opposite knee.  The stretch can be extended by either lightly pushing the flexed knee down towards the floor or by leaning forward at the waist and allowing your body weight to increase the stretch. Hold the stretch for 5 to 10 seconds and then slowly relax.

How do I do massage or trigger point release of the iliotibial band?

What are some strength exercises for Iliotibial Band Syndrome?

 

Strengthening the gluteus muscles and other muscles that help stabilize the hip while running is very important.

Step lunges and leg squats can help increase gluteal muscle strength and are helpful for prevention of iliotibial band syndrome.

For athletes that are trying to rehab from IT band syndrome, we recommend a gradual approach to strength training of the gluteal muscles.

Side Leg Lifts

Side leg lifts focus on strengthening the lateral gluteal muscles as well as teaching you the correct muscles to focus on. Side leg lifts are performed lying on the side, with the injured leg on top.

Keeping the hip and knee straight, slowly lift the top foot twelve to twenty-four inches directly above the bottom foot.

Hold the position for 5 to 10 seconds and slowly return the leg to the starting position. Focus on using the gluteal muscles and not the lateral thigh muscles to lift the leg. Repeat this exercise 5 to 10 times in sets of 2 or 3.

Single leg pelvic bridges

Single leg pelvic bridge exercises can help focus on strengthening and firing patterns of the gluteus medius and gluteus maximus muscles.  The single leg pelvic bridge is done laying down in the supine (on your back) position with the knees bent and feet flat on the ground. Lift your hips off the ground until your back, hips and thighs are straight.

Then slowly straighten out one leg and hold for five seconds. If you feel most of this exercise focused in your hamstring, one trick is to keep the heel of the foot on the ground while flexing the ankle. You should feel most of the focus in the gluteus muscles at this point.

Don’t despair if you feel weak or shaky doing this exercise. It’s a difficult exercise to do, but great for improving gluteal strength.

 

Key Points to Remember for IT Band Syndrome

There are several key points to remember with iliotibial band syndrome. The focus should be on stretching and strengthening the muscles around the hip (and not the iliotibial band) since weakness in these muscles often is the primary cause of the injury.

Limiting increases in running mileage to approximately 10% weekly can help prevent injuries from “too much, too soon.”

It’s also important to monitor training intensity as well, since higher intensity workouts such as track workouts without proper recovery may lead to a running injury.

Sometimes, worn running shoes with poor arch support can lead to excessive pronation of the foot and increased stress on the iliotibal band. Remember that most running shoes last for 300 to 400 miles and need to be replaced. Having an expert at a running shoe store can help in selecting the proper shoe for your foot and running style.

Don’t forget the importance of recovery and moderation in an exercise program. While a little soreness is a sign that your body is adapting to the increased training, pain is your body’s signal to slow down.

Return to Running after Iliotibal Band Syndrome

The often-asked question of most runners and endurance athletes is when they can return to running with iliotibial band problems.

A gradual return to running can begin once an athlete can perform the exercises without pain. While individual results may vary, most ITB syndrome cases resolve with 4 to 6 weeks of rehabilitation.

A return to running program should focus on proper biomechanics and avoid triggering factors (sloped or uneven surfaces). Studies have shown that faster paced running has less irritation of the iliotibial band due to the flexed position of the knee at foot strike versus slow paced jogging.

We recommend easy and short fast-paced running on alternating days on flat ground for the first week with a gradual return to longer, slower paced runs over the next 2 weeks. Additionally, avoiding downhill running or on sloped surfaces (side of the road) can help prevent re-injury.

The rehab stretches and exercises should continue during the return to running phase of the training program.