Iliotibial Band Syndrome
Similar to patellar tendinopathy (PT), iliotibial band syndrome (ITBS) is relatively straight forward in its diagnosis as the pain is on the outer portion of the knee where there aren’t many other tissues to consider that may be sensitized. Certainly, there are more sinister conditions to rule out initially as with any episode of pain or injury, but these are much less common for this area and correspond with other factors and pain behavior.
The ITB is a long and tough fibrous fascial tissue the runs from the side of the pelvis, down the outer thigh, and inserts into the outer portion of the knee. It functions and behaves much like a tendon when sensitive.
Historically, ITBS was thought to develop due to friction occurring with movement as the ITB is sliding over the insertion(s) causing irritation. This was believed to sensitize the underlying well innervated fatty tissue with cyclical loading such as during running. 1 However, this explanation has been questioned more recently. In view of the anatomy and observing the biomechanics of the ITB specifically, it appears almost impossible that the ITB could be gliding over the insertions and underlying tissues. 2 An alternative possibility is that the tensioning of the ITB during use creates an illusion of movement while under imaging but is ultimately creating varying compressive forces on the underlying tissues thus sensitizing them after prolonged durations they aren’t accustomed to.
1. Skip the foam roller and “ITB specific stretching” (Reference 3- 6)
Because ITBS is more of a reaction to the compressive forces, we want to aim to avoid activities and positions that create compression, which is frequently seen while foam rolling or stretching. This is not an anti-foam roller or anti-stretching proposition. If you love these things and find them beneficial, continue using them. However, we need to understand what these modalities are doing to us and, even more importantly, what they can’t do so that we can make the best informed decision on how to address out symptoms for long term success.
In 2018, Chaudry et al showed that it takes roughly 2,000lbs of force to deform the ITB by 1%! So, what’s happening when laying on a foam roller from a mechanical standpoint? Virtually nothing. That novel noxious stimulus can have a profound, but temporary, effect on the nervous system by dampening its to the pressure. Often, this can help decrease symptoms in the short term. “Since ITBS is considered a compression syndrome, prescribing additional compression, via foam rolling, lacks biological and mechanical justification, and may conceivably exacerbate ITBS.” (Reference 5)
Performing “stretches” for the ITB is, unfortunately, equally effective. Check this out! Through the work of Willet et al, we learned that the Ober test is unaffected when the ITB is cut versus when it wasn’t. The Ober test is supposed to test the tightness of the ITB and looks very similar to methods of stretching it. If you have ever had the opportunity to observe or participate in an anatomy lab and evaluated the ITB, you know there is no way you can stretch it out. It is an unbelievably tough tissue! Interestingly, research has shown that those with and without ITB related symptoms have comparable stiffness. Taking this idea a step further, when people with symptoms were followed through 6 weeks of physical therapy, the stiffness of the ITB increased! Mind blowing?! Confusing? I felt the same when I learned all this a year or two after completing my professional training.
2. Hip strengthening (Reference 7-10)
The ITB functions much like a tendon. When tendons are sensitive, they commonly have decreased stiffness. Stiffness here is a good thing creating an environment where the lateral hip muscles don’t have to work so hard. Recall the effects of physical therapy on the ITB stiffness above. This stiffness of the ITB creates an environment where those hip muscles don’t have to create or absorb as much force.
Similar to the development of patellofemoral pain (PFP), a lack of strength doesn’t cause ITBS. Nor does it relate to increased hip adduction, a position thought to increase ITB strain and thus symptoms. Improving your lateral hip strength does seem to help with symptoms, even though is does not improve hip adduction while running. Arguably, the program utilized by Willy et al was not intensive or specific enough to elicit changes in running specifically. However, a much more likely mechanism as to how this intervention helps is by restoring and/or improving tissue quality through a progressive strengthening program allowing greater tolerance for the demands of running.
3. Increase cadence (Reference 11-13)
I have talked a lot about cadence in this knee pain series. I want to make it clear that increasing cadence is NOT a silver bullet. It can be incredibly helpful for many, but not for everyone. Even when we consider the 165-170 steps per minute threshold discussed in the patellar tendinopathy article, some people don’t need to modify their cadence. Runners with longer legs naturally have a slower cadence than those with shorter legs. Therefore, for some, increasing cadence may not offer much of a return and there certainly isn’t anything magical about standardizing everyone to 180 steps per minute, as some in the running community have proposed.
Similar to what we see at the level of the patellar femoral joint and patellar tendon, we see the same effect at the level of the ITB with the strain and strain rate when shortening your stride length and widening the step width. The easiest way to do this is by quickening your cadence, which will invariably shorten your stride length. That alone should be enough to utilize this intervention, but there is more! With that shortened step length, there is also a concurrent increase in step width. Therefore, one intervention is giving us two avenues to decrease the strain and strain rate of the ITB while running! That’s huge and certainly an intervention worth considering when the ITB is sensitive.
If these steps don’t do the trick for you, please don’t hesitate to reach out for help to me or another trusted health care professional. You can connect with me via phone at (719) 270-3155 or email at runmental@gmail.com. I am also active on Instagram and within my Facebook group, Strength in the Springs, where I frequently post educational material about running rehab and training.
Happy running!
1. Renne J. The Iliotibial Band Friction Syndrome. J Bone Joint Surg Am 1975; 57:1110-1
2. Fairclough J, Hayashi K, et al. The Functional Anatomy of the Iliotibial Band During Flexion and Extension of the Knee: Implications for Understanding Iliotibial Band Syndrome. J. Anat 2006; 208:309–316
3. Chaudry H., Schleip R., Zhiming J., et al. Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy. JAOA 2008; 108:379-390
4. Wiewelhove T., Doweling A., Sneider C., et al. A Meta-Analysis of the Effects of Foam Rolling on Performance and Recovery. Front Physiol 2019; 10:376
5. Willet G., Keim S., Shostrom V., et al. An Anatomic Investigation of the Ober Test. Am J Sports Med 2016; 44:696-701
6. Freide M., Klauser A., Fink C., et al. Stiffness of the Iliotibial Band and Associated Muscles in Runner’s Knee: Assessing the Effects of Physiotherapy Through Ultrasound Shear Wave Elastography. Physical Therapy in Sport 2020; 45:126-134
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11. Tenforde A., Borgstrom H., Outerleys J., et al. Is Cadence Related to Leg Length and Load Rate?. JOSPT 2019; 49:280-283
12. Boyer E., Derrick T. Select Injury-Related Variables Are Affected by Stride Length and Foot Strike Style During Running. Am J Sports Med 2015; 43:2310-7
13. Meardon S., Campbell S, Derrick T. Step Width Alters Iliotibial Band Strain During Running. Sports Biomechanics 2012; 11:464-72