Last updated: 19-Jul-18
By Karina Teahan
So many runners suffer from pain and tightness in their IT bands. It is one of those things that can start as a niggle and then become really debilitating. Here, I look at everything ITB: what it is, why it can become painful, and how to treat it with care.
What is the Iliotibial Band (ITB)?
First for the technical description – bear with me on this!
The ITB is a large sheath of fascia running along the outside of the thigh, from just above the hip bone, down over the femur to just below the knee into Gerdy’s tubercle (located on the lateral side of the tibia bone) blending with fibres of quads and hamstrings. Some fibres also run onto the patella.
Fascia is similar in lots of ways to tendon, it is very tough, and a little bit elastic. Fascia is made up of large sheaths whereas tendons are more rope like.
The ITB is the largest piece of fascia in the body. It is connected to a number of important muscles including the Gluteus maximus (Gmax) & Glut Med (Gmed) and the Tensor fascia latae (TFL) muscle. Additionally, the ITB is connected indirectly to muscle in the Lumbar spine.
Function of the ITB
The ITB helps certain muscles flex your hip, lift your leg out to the side, stabilise it and turn your leg inwards. It also helps keep your knee in a better position when you are running, cycling & walking. The interactions of the ITB will involve the lumbar spine, hip and knee.
What is Iliotibial Band Syndrome (ITBS)?
ITBS can show up as pain (sharp/burning/aching) on the outside of the knee about an inch above the lateral joint line of the knee. Repeated bending of the knee will produce the pain – not a good thing for running. It can be particularly bad when the knee is slightly bent to about 30 degrees. It can move out to the outside of your calf from there. It is aggravated by running and in particular downhill.
Be aware – perhaps you do not have ITBS at all! Many conditions may mimic ITBS but a thorough assessment by your Chartered Physiotherapist will identify the true injury. It really is worth going for an assessment if you have pain as you can then move forward to treatment rather than letting it get worse.
What Causes ITB Syndrome?
What is present is a highly vascularised and richly innervated mass of fatty tissue that contains nerve fibres under the ITB at the site where pain is felt. So pain can be produced if this area is overly compressed which is what happens when a combination of the risk factors below is present.
Compression can be cause by a number of risk factors both internal (from within the body) and external/environmental.
- Weak hip abductors especially glut med. This causes more tension to develop on the ITB as the other muscles going into it have to assist more in keeping the hips level during the run.
- Excessively pronated feet
- Excessive track running
- Running on a camber
- Excessive downhill running
- Long distance running more so than sprinting due to the knee angle at foot strike.
- Bow legs
- Leg length discrepancy
- Tight hip/lumbar spine, or the muscles that attach around these joints. They will have a remote influence on the ITB load.
- Sudden increase in mileage (as always risks any overuse injury)
- Runners with ITBS have also been found to be weaker in their quads and hamstrings – part of this may be pain inhibition of these muscles due to the injury. Pain can cause muscles to switch off, effectively going on strike!
- Cyclists may also develop ITBS and correct positioning of the foot cleats and overall bike set up is vital to address this.
Incidence
The incidence of ITBS is thought to be as high as 12% of all running-related overuse injuries.
Treatment/Management
- Stop! Rest! Allow the pain to settle down and avoid pain provoking activities. Some physiotherapists would suggest rest from athletic activities for at least three weeks, other say one week to two months but this really depends on the severity of your injury. A milder presentation may allow you to continue training but at a lower intensity.
- Use ice in the acute phase for the first three days, in particular every 10-15 minutes as many times as it feasible in your work/home schedule.
- Examine what caused it (see risk factors above) and aim to address whatever deficit applies to you.
- Applying pressure to the soft tissue and the fascia and trigger point release (manually or dry needling) of the hamstrings, quads, gluts can greatly reduce pain in the affected area. In some situations, it may cure the condition. Remember, if these key muscles are underperforming, they will cause that excessive compressive load on the ITB.
- Foam rolling: Beware! From a purely personal point of view I feel that this will actually aggravate your pain in the early stages of the injury as it just results in compressing further the already compressed irritated area. Foam rolling is good as a preventer or maintenance of mobility down the line as it can release trigger points in the quads and hamstrings. You cannot stretch the ITB per se as it is mainly made up of collagen but you can stretch the muscles attached to it.
- Address your foot. If you are overly pronated, you may need to be assessed for orthotics or at least wear a running shoe that is right for your foot to control this excessive motion and support you in a more neutral position. I find running specialist stores so helpful in helping decide the proper running shoe for your foot type. This should be done in conjunction with strengthening the muscles that support your arch. (See Tib Post strengthening exercise photo below).
In standing tie a piece of Theraband/resistance band around your ankle, try to create an arch with your weight bearing foot but keeping the toes and heel on the floor, bend your knee slightly then step over and back above the band. Keep your foot in this good position for 10 reps.
- Address flexibility issues in your hip, gluts, lumbar spine. Adding an overhead side flexion stretch (to the opposite side) in your standing stretch will help incorporate the muscle around your lower back.
- Ideas for working on strength deficits in your gluts include:
Squats: single leg or double leg
Add weights as able, try to go progressively lower as you get stronger but only if you can keep your knee in a good position. Repeat x10.
Side plank – progressing to leg lift. Repeat x10:
Leg press single and double
Mind knee position on the foot plate throughout and gradually increase weight and range you move through. You will find this machine in most gyms -just ask!
Romanian Dead Lift’s (RDLs); single & double with weights:
Remember to keep your back & shoulders straight, knees slightly bent. Bend from the hips, and keep your arms relaxed. Drive your hips forward as you come back up.
Keep the standing leg slightly bent, keep your back & shoulder straight, aim to get to a stable steady “T” position.
Hip dibs (standing):
Standing on the side of a step, let your hip drop over the step then use the gluts & the muscles at the side of your hip (on the standing weight bearing leg) bring your pelvis back to level. Repeat x 10.
Hip abduction in side lying +/- Thera band
Lying on your right side, legs out straight, lift the top leg up & down about 30cm off the floor, point the toes away as you lift, point the heels away as you lower. Tie Theraband around your ankles to add resistance. Repeat 10 times each side.
Note: strength training should only be done three days/week and not on consecutive days. Start with low weights to achieve the correct technique. Use a mirror for feedback.
- Cross training: you can get a great cardio work out from swimming but may need to use the pull buoy in the acute phase of your injury when kicking will be painful.
- As you progress through your recovery phase you can add running, jumping, and agility work. Your aim is to have your affected leg performing as well as your uninjured leg.
- Progress slowly, allow tissue time to heal and do different training. Do not attempt to progress exactly from where you left off before you got injured. Keep an exercise diary and remember the 10% progression rule!
All images: Karina Teahan.
