ITB. ITBS. ITBFS. Runner’s Knee.
Call it what you want, issues with the Iliotibial Band can be a bugger to treat. A quick search on the Runner’s World Forum shows over 3500 posts on the ITB. With so many people encountering this problem I thought it was the ideal place to start when creating a blog about running injuries. So here goes….
What is ITBS?
The ITB is a thick fibrous band that runs from the iliac crest down the outside of the leg and across the knee joint, connecting to the outside of the patella on it’s route. It crosses both the hip and the knee joint and has a role in stabilising both.
The terms Iliotibial Band Syndrome and Iliotibial Band Friction Syndrome obviously mean the same thing but there has been some debate about whether this condition involves “friction”. The longstanding theory is that the IT band runs over the femoral condyle as the knee bends creating friction, inflammation and pain. Recent literature has challenged this view saying there is a highly innervated layer of fat between the femoral condyle and the ITB and it is this that becomes inflammed and painful. Either way the result is pain, usually felt on the outside of the knee and around the IT Band.
What causes ITBS?
So many treatments aim at symptom relief for the ITB but to get rid of an ITB issue long term you need to examine the cause and deal with that. It isn’t just tightness of the ITB that’s an issue, it’s also the load and stress on the ITB and the frequency at which it finds itself under load. For example a sprinter may have a really tight ITB, but only runs for 10-20 seconds in a race exposing the ITB to high loads but only briefly. A marathon runner with a slightly tight ITB will be running for upwards of 3 hours (obviously depending on level) so while the load might be lower on the ITB it is exposed to it for far longer.
1. Increase in mileage/ changes in training
It’s a common story for runners, “I’d just done my first 18 mile run when…[insert injury]…”
The increase in mileage places a stress on the legs that they aren’t capable of dealing with. The high load on the ITB causes inflammation and pain. Of course mileage isn’t the only variable, it might be an increase in speed, or hill work, a change of running surface or how you space your runs out over the week. Research has shown that if you load tissues everyday (I.e. running everyday) that overall there can be a net break down in collagen (the stuff that makes up a lot of our tendons, ligaments, muscles etc). If this continues over a period of time it weakens a tendon/ ligament and it’s structure changes. It becomes worse at dealing with load and you start to create a vicious circle. This is especially true with the Achilles. So, in short, if your run everyday without rest you run the risk of problems in tendinous structures like the ITB.
Obviously prevention is better than cure so train wisely. Don’t increase weekly mileage by over 10% per week. Have a rest day after long runs. Run long runs at an appropriate pace. Mix up running surfaces where possible to change the stresses going through the legs. Don’t be afraid of rest or swapping in cross training. Keep an eye out for over training or being in the red.
Of course all this may not help you if you already have ITBS but if you feel it developing it may help stop it from progressing. When training with ITBS try and find a way to train pain free. Can you do it by slowing down? Or even speeding up (some research has suggested running faster may actually be better for ITB)? Is it better if you run on the treadmill or grass and not concrete? What about if you regularly change road position to avoid the camber of the road? Does it stop it hurting if you use a run-walk-run pattern? What about if you use a foam roller before you run or taping to offload it (we’ll look at this shortly)? In many cases a few changes to your training can resolve ITB issues. I used to get ITB tightness after 7-8km. I can now run 20 miles with no ITB symptoms at all.
What if you can’t find any way to run without your pain coming on? I’m afraid you need some Proactive Rest.
No runner likes to stop running. As I write this I’m forcing myself to have a rest day from my marathon training. I hate it! I’m restless and it’s a stunning day outside, I want to be out in it but I know I’m in the red, experience tells me if I keep running I’m going to pick up an injury. It’s hard for a non-runner to understand how hard it is to rest at times. That said sometimes it’s the only answer. If you can’t modify your running to run pain free, or at least at a level where it’s manageable, then you need to rest from running to settle your symptoms. You can cross train, again if pain free during and after, but if you can’t cross train without pain then you will need to rest.
Rest. The R-word. Why is it sometimes harder to rest than train!?
Rest will help the inflammation around the ITB to settle. You may want to add in ice and anti-inflams to help this process.
There is an issue though with rest, when you run again the issue often comes straight back. This is part of the reason why people don’t want to rest. So Proactive Rest is the plan. Rest to let the inflammation settle, self treat to reduce symptoms and deal with the underlying cause. Then run. Run like the wind!
How long should you rest your ITB? Tricky question, mild inflammation may settle in 2-3 days, more severe may require weeks. Be guided by your symptoms and most importantly of all have a graded return to running. Don’t go straight back to your previous level. Start with a slow, gentle jog and gradually build up with rest days between each run.
2. Muscle weakness – mainly Gluteus Medius, Gluteus Maximus and Medial Quads
The glutes have a lot to answer for! How many running issues are now chalked up to weakness in the glutes!? In ITBS the culprit is often Gluteus Medius (GM). GM abducts the hip, taking the leg away from the body, and the anterior fibres are thought to internally rotate the hip and the posterior fibres externally rotate. If GM is weak or isn’t kicking in quickly enough then another muscle, Tensor Fascia Latae (TFL) often becomes more active to compensate. As TFL attaches to the ITB this can place greater tension on the ITB and contribute to the problem. The longer and harder we run the more likely it is that GM will fatigue, TFL will become more active and the ITB will tighten up.
Now this isn’t as straight forward as it sounds. Not every ITB issue is from weak glutes hence why not everyone will get better with glutes rehab.
Gluteus Maximus (GMax) extends the hip and has a major role in supporting the leg and trunk during the stance phase of running (the time when the foot is on the floor). It also attaches to the ITB and has a role in externally rotating the hip. Any weakness in GMax is clearly going to affect running and the stability of the pelvis and thus the ITB.
The medial part of the quadriceps (on the inside of the quads) often referred to as VMO (Vastus Medialus Obliques) was hugely in vogue in Physio up until fairly recently. Every knee problem was treated with “VMO exercises” as it was thought that by building up this part of the muscle you could help with the tracking of the patella. More recent research has suggested it’s very hard to work just the VMO and that the benefit from VMO exercises was actually just general quads strengthening. The quads control the knee position when the foot strikes the ground and the knee bends. Weak quads contributes to poor control of this movement and as a result greater stress on the ITB.
Strength work for these 3 muscle groups seems to help in the majority of ITBS cases. The challenge is strengthening without aggravating the ITB. Many of the exercises will also load the ITB so the aim is to work within pain free limits. Here are some simple exercises for the quads;
Runner’s world have produced a nice article on glutes exercises. The exercises in the video are, by and large, very good. Everyone does rehab and little differently and you will see lots of variations on this but the exercises they mention will work GM, GMax and the quads. I plan to upload a video of exercises myself in the near future and I’ll add them to the blog in due course. In the meantime I’ve written a blog on Gluteus Medius strengthening, grab a cuppa it’s a long one!
3. Tissue Flexibility.
Some people are flexible and others, like myself, aren’t! There are some advantages to having hip flexors and hamstrings like tight guitar strings – tight tissues may help transmit force better. Imagine a loose floppy spring, would it bounce? What about a tightly bound spring? You get the picture. The technical term is elastic recoil. There is, of course, a balance between overly flexible tissues and rigidly tight ones.
With ITBS the key areas are hip flexors and quads, TFL and the ITB itself. In addition anything that affects movement of the knee can have an effect e.g. Calf and hamstring tightness.
There is some debate as to whether you can even stretch the ITB! It’s such a tough, broad band some people say you can’t increase it’s length. That said stretches do seem to work for people but it may be that it’s actually TFL that is stretched. The question is how do you stretch it? Hopefully this research should provide some answers (check out figure 2).
Stretching the hip flexors is also important, if the hip flexor is tight it makes it harder for gluteus maximus to control extension of the hip. I use something I call the “sofa stretch” I use it after every run and it’s the only stretch I’ve found that I feel in my ITB. It’s really helped me, here’s the video;
Static stretches are best done after exercise, but you can also have a specific stretch sessions on days you don’t run. Make sure the area is warm and ready to be stretched, after a bath or shower is a good time. You could heat the area with a covered hot water bottle first. Never be overly aggressive with stretches, gradually work into it. Hold for 30 seconds or more, I find 3-5 reps is adequate.
4. Movement Control
Strength is of little use without control. Each time your foot strikes the floor as you run your muscles must react to keep you upright and moving forward while maintaining your upright body position. It’s not unusual for a runner to be very strong on muscle testing but unable to balance on one leg.
If your control of leg movement isn’t great then your femur may adduct (move towards the other leg) and internally rotate during impact. This places a greater stress on the ITB and can lead to pain.
Check your balance – can you balance on one leg for 10 seconds and keep your pelvis and leg steady? Can you do this with your eyes closed? Try a single knee dip and see if your knee drifts in or if you feel unsteady. Info on how to assess and rehab your balance here.
If your balance is poor you can improve it by working on it. Once you can balance easily on one leg for 10 seconds try it with your eyes closed or on a pillow. Balance and move your upper body side to side or rotate your trunk. Try slow controlled single leg dips aiming for the knee to move in line with your second toe. You can also use a wobble-board or rocker-board or the Wii Fit Balance Board which has lots of balance based games on it.
These areas, although presented separately are all inter-linked. Take movement control for example, without adequate strength you can’t control movement, and biomechanics plays a part too. If you tend to over-pronate then as your ankle turns in the rest of the leg will follow, adducting and internally rotating the femur and placing greater stress on the ITB. Good movement control and glute strength may help counteract this but if there are severe biomechanical issues then it become much harder for the body to compensate.
Ensuring you have the right shoes for your foot type and having your gait analysed are sensible steps for any runner but especially so if you have developed ITBS. There are so many variables with shoe selection, we tend to focus on how much they prevent over-pronation but this is just one factor. We can theorise endlessly but the only way to really test a shoe is to run in it. Some running shops will allow you a 30 day period to run in the shoes and return them if you have any issues, this can be really useful in finding the right shoe for you.
Aside from over-pronation, common causes for ITBS include leg length discrepancy, and altered knee or hip position. Assessment from a Physio or Podiatrist can help identify these issues and determine how they may be addressed. A leg length difference can often be treated with a simple heel raise in the shoe, more complex biomechanical issues may require custom made insoles provided by a Podiatrist.
That said, none of us are biomechnically perfect. Most people have a slight leg length discrepancy. I have low arches, bowed knees and a leg length discrepancy! I run in a stability shoe (Gel Kayano 18s) and have very few problems. Sometimes your body can compensate for these issues if you have adequate strength and control.
Identifying the cause of ITBS is an important piece of the puzzle, if you just focus on settling the symptoms it may well come back when you start to run. That said, settling the symptoms is essential if you want to rehab and return to running.
Your aim here is to reduce inflammation and tightness.
- Rest – this may be complete rest if symptoms are severe and easily aggravated. It may be you can cross train or keep running but if you do either you need to find a way to keep it pain free (both during and after).
- Ice – use for 10-15 minutes over the painful area 2-3 times per day to reduce inflammation
- Anti-inflammatories – this is a debateable one. One view is that they are very useful in reducing inflammation and allowing quicker return to rehab. The other is that they may interrupt the natural healing process, and have side-effects like all medication. The choice is yours. If in doubt, discuss with your GP especially if you have stomach problems or asthma.
- Massage/ foam roller – start by massaging the non-painful areas of the ITB, including the TFL at the top. You can progress on to the more tender areas when tolerable. It should feel better after. If you are massaging an inflamed tender area and it’s just getting worse stick to the other areas of the ITB until it settles.
- Stretches can help settle symptoms if it’s not too sore (see details above)
- Heat/ steam room/ jacuzzi/ sauna – for more chronic ITBS heat may be more useful than ice. It helps relax tight muscles and reduce pain.
- Taping to offload the ITB (details below)
- Self mobilisation of the patella – part of the ITB attaches to the patella so gently mobilising the knee cap helps to maintain range, stretch part of the ITB and reduce pain. On a safety point I wouldn’t do this if you have a history of patella dislocation or hypermobility syndrome (unless you’ve been advised by a Physio who’s actually assessed you).
Supportive tape can be an excellent way to offload the ITB and reduce pain.
McConnell taping helps to support the patella that can be pulled laterally (towards the outside of the knee) by the ITB if it’s tight, causing pain. This article goes into more detail.
Another taping technique that helps by increasing support of the knee during impact is this, more general knee taping;
Treatments you can’t do yourself….
While you may be happy to self tape or gently manipulate your patella, you can’t do improvised acupuncture using the pointy end of a fork! Shame really! Acupuncture can be very effective in both reducing ITB tightness and inflammation. Acupuncture now has a respectable body of evidence behind it’s use in reducing pain. It has also been shown that inserting a needle into a muscle tends to cause that muscle to relax. You can use points along the ITB, in TFL and glutes and also “distal” points away from the ITB involved in triggering the release on natural pain relief in the body (opioids). This article explores it in some detail.
Acupuncture is available in most NHS Physiotherapy departments (around half the staff in my NHS clinic do it) and some private clinics (ask before you book an appointment).
Ultrasound must be the Marmite of the Physio world! People either love it or hate it! Patients will come in and ask just for ultrasound at times and yet others turn there nose up at it in disgust. It’s fair to say that on its own ultrasound has little benefit, but combined with a rehab programme it can help reduce inflammation and aid healing.
ITBS can be a complex and painful condition. Key strategies to manage are find the cause, settle the symptoms, rehab where needed then plan a gradual return to your normal running.