I have been either studying or working in Sports Medicine since I entered Marist College Athletic Training Education Program in 2001. I had no major injuries even though I was an athlete from the age of 3 through college. I always thought that my patients with overuse injuries had a bit of a soft side to them and were looking for an easy out as all of my injuries I was able to play through or missed very little time of practice or competition. From 2005-2010 I was very sporadic in my exercise regimen, okay, it did not exist at all. I neglected my body and when I got back on track and started off in endurance sports I met my first overuse injury. I was running some stairs (never again by the way- that is what you get for trying to train yourself anyone want to guess which author?) and it felt like someone stuck a hot knife in the side of my knee. I ran back the 2 miles to my starting location with this grinding and clicking that reminded me the time the transmission blew in my Camaro and I had to limp home in 1st gear. Thinking I was just having a bad day I went out the next day for the next run was and BOOM! Less than a mile in and I am officially injured. My mind immediately went past ITBS and thought this must be a Lateral Meniscus Tear or I avulsed something off because it hurt so bad.
After the panic settled down I was able to self diagnose myself and started to try and manage everything myself through some basic rehab. My stubborn personality kept trying to check and tryout the my knee and I kept getting hit with the same result. I went into one of the clinics I work for and had one of the non-surgical docs look at me. They are creative in their treatment plan and I wanted to be aggressive. I got the all clear on the rest of the joint and left with a few crappy scripts, one for a Rx grade NSAID and on some voodoo topical cream from a compound pharmacy. So next visit was to get aggressive and get the big needle for some cortisone into the target tissue. Yup, that did nothing either, but had some decent video for class. I made a stupid mistake and started reading about others have done for this. So the next visit was a Graston Therapist, pretty cool technique. It was unique manipulation of the tissue it was aggressive yet superficial in my observation. When I got no relief from about 3-4 sessions it was off to the next guru. I went to an Active Release clinic. Super knowledgeable chiropractor I worked with and he totally made progress with my tissues over a dozen sessions, one problem, my IT band issue did not go away. I got a Rx for MRI and got some images as I was convinced now again that this was a lateral meniscus tear. And the MRI read, IT band looks pretty good but you have a MEDIAL meniscus tear. Sometimes having a knowledge of something isn’t the most beneficial as we can see through process I have already been through. I was still at square one and about 3 months into this thing. I was now determined to get to the bottom of this thing. I got rid of everyone and went off and got on pub med and literally downloaded every piece of literature I could on ITBS, Abductor weakness, etc etc… My research led me to some major articles by Fredricson and Fairclough where most of the following protocol was derived from. I also pulled inspiration and techniques from Kelley Starrett of MobilityWOD. In an attempt to just get to it already, I had a final massage therapy session with a woman I instructed to tear me apart. She spent an entire hour freeing my ITB and destroying and unwanted adhesion’s and trigger points. She owned me, I swelled huge and barely walk. It felt like I had a rubber band in my knee. I did an entire week down with swimming only, and followed every successful mobilization, stretch and strengthening therapeutic exercise that has been proven by research. Now that I gave you my personal background with ITB let me give you my professional take on the condition. I will try to keep this in layman’s terms I am just not good at writing that way and this may turn up just being clear as mud in a jar. Here it goes.
Decades of runners and cyclists have been plagued with the infamous Iliotibial Band (ITB) pain. Iliotibial band syndrome (ITBS) usually presents as sharp or burning lateral knee pain. The pain is often reproducible and rears itself early in a workout often at a specific time or distance stopping the runner in their tracks. This debilitating pain usually subsides rather quickly with only lingering symptoms occurring with ascending and descending stairs. This article will review condition and provide rehabilitation strategies for managing ITBS.
The ITB is a thick band of fibrous connective tissue that originates on the iliac crest sharing fascia with the gluteal muscles and Tensor Fasciae Lata (TFL) proximally and continues down the lateral aspect of the leg tying in with the Biceps Femoris and Vastus lateralis where it crosses the knee joint over the lateral epicondyle inserting on to the Tibia.
When a person runs their hip and thigh muscles help to stabilize the thigh and pelvis. The range of motion of moving your lower extremity at the hip away from the mid-line of the body is called abduction. During the running gait at the initiation of the swing phase of one limb the opposing leg is in full contact with the ground at mid stance and the pelvis should remain stabilized by the active muscles of the TFL and Gluteus Medius to prevent “crashing” or a Trendelenburg’s gait pattern by abducting the hip.
The ITB is a thick tendinous extension of the TFL. Tensile strength of the ITB has been reported at 7800 psi or the same as soft metal. The ITB shares some attachment with the lateral patella as it crosses the knee joint before inserting onto the lateral tibia. As the knee flexes around 30 degrees an area of friction or compression occurs at the lateral knee. Irritation occurs at this location (impingement zone) causing inflammation of the underlying tissues of the posterior side of the ITB, Bursa and fatty tissue. Chronic ITBS suffers may even develop thickening of the ITB in this area further exacerbating the condition. Some studies have even shown bony erosion occurring at the lateral epicondyle in the most severe cases.
So why do some athletes get this injury and others do not?
Am I just tight? You are tight but that probably isn’t the entire story. The Ober test is a standard clinical laxity stress to to evaluate tightness of the ITB. Tightness of the ITB will present with the leg not falling into adduction past neutral. A fair assumption is that if we are qualifying compression or friction as the mechanism of injury than a tighter structure would cause more of impingement to occur further increasing the problem.
What causes this tightness? It was mentioned in the anatomy section that the ITB is a biarticular structure that shares fascia connections throughout the hip and thigh which makes this a complex question. The common belief is that the ITB itself is tight when it is rather a more global problem affecting several muscles of the hip and thigh. A trigger point is an area of restricted tissue. All trigger points are not created equal and restoring these tissues often requires movement patterns and manipulations that differ from traditional techniques. With ITBS we often see restrictions proximally in the entire hip region, restrictions can be found in the flexor component of the TFL (which also is in charge of abduction), the Gluteal muscles and the hip rotators. So what is not affected? Not much! We are plagued as a society that most of us sit entirely too long. We develop contractures, tightness and a laminating effect of our tissues through lack of movement and spending most of our time in a far from ideal position. As we move distally we see restrictions in muscles that connect directly to the ITB which include the Vastus Lateralis and the Biceps Femoris. Getting “slack” and allowing these muscles to slide on each other normally again is the mission and one that often requires habitual attention. There have been some contradictory research that shows a correlation between excessively mobile ITB and ITBS but far more has been published on the other end of the spectrum.
Am I just weak?
I mentioned tightness first because I feel that there is a connection between tightness and weakness and it is often similar to the chicken and the egg question; which came first? I think the answer to this varies but they may be interconnected or one may have caused or exacerbated the other. We can see a phenomenon called reciprocal inhibition or what might be easier to understand as “Opposing Deactivation” occur in the muscles that affect ITBS suffers. Our muscles work in opposing pairs called agonist (primary mover) and antagonist (the muscle that goes on stretch or opposes this muscle) the simplest or most common example is the Biceps and Triceps of the upper arm. When the Biceps muscle is contracted the Triceps muscle goes on stretch. Now imagine if we transplanted someone’s Triceps muscle with a wooden dowel that was 2 inches shorter than the maximum length the muscle normally stretches too. We would see a major restriction in the amount of elbow flexion that would occur creating a deficit.
Now weakness may be the chief cause of the tightness which starts this cascade of events. Using our same example of the biceps and triceps, if the person developed a major biceps tear which caused significant weakness in the range of elbow flexion. The lack of exposure the triceps will receive in a stretching capacity will increase. The response from lack of stress being applied to them is that the activity in that muscle will be very low and will have tendency to stay in that position more. The sliding surfaces get sticky and matted down and the muscles adapt to the new stress level that is placed upon them. since we function primaily as a species based on the SAID principle specific adaptations to imposed demands. The adaptation for something that isn’t stressed in a range of motion very often is that the structure gets tight, restricted, and “gummed” up.
We classically see hip abductor weakness in ITBS patients. The Gluteus Medius is in charge of abduction in midstance and is in charge of preventing the pelvis crashing down on the opposing side which creates a huge amount of biomechanical compromise creating large amounts of tension in the ITB system when the foot is in contact with the ground in the running gait. We will address strategies and exercises that target this musculature in later sections. This muscle ends up being the culprit in a lot of cases and if punished accordingly will comply with what it is asked to do in the running gait.
So the answer to what cause ITBS is complex and often has many contributing factors that we will need to manage over time to resolve symptoms.
So what can we do to resolve ITB pain?
Finally what you have all been waiting for!
A regimen of mobilization, stretching and strengthening is a recipe for success. Let’s start by exploring stretching. There is something to be said about getting tissues in a good position prior to performing strengthening.
Let’s dive into mobility first
DISTAL QUAD SMASH WITH LAX BALL
In a prone position (face down) place Lax ball just above the patella (knee cap) shift weight to side of lax ball pinning down tissues, flex and extend knee repeatedly until any crepitation or tightness resolves For up to 3 mins. Note you may find an area of “Gristle” on the lateral border of the patella with connections to the ITB, do not be afraid to spend some time here and clear that area. You can also move this lax ball against the entire length of the ITB peeling the Vastus Lateralis and Biceps Femoris off of it ungluing the tissues and gaining extensibility. If you are really brave corner the ball inbetween the ITB and the Vastus Lateralis or Biceps Femoris and roll in a similar manner as you would on a foam roller.
In a prone position start foam rolling quadriceps rotating to a side lying position and mobilizing vastus lateralis , pay additional time mobilizing tissue connection points of Vastus Lateralis (outside part of thighs) to the ITB. If you find a trigger point or tender spot do not roll past it but oscillate and rotate (almost like a spooning or scooping motion on the tissue) on that area until that tissue releases. (Yes! If you are doing this for the first time you will want to die…No eye water please)
MWOD inspired Hip Opener
Start in quadraped (on all fours) position. Cross affected side across the body and locking it in front of opposite knee. Shift weight to the side with the leg that is being crossed. Shift hips laterally in the frontal plane (like your sticking your hip out to that side) and scour and oscillate on that side you should feel like the head of your femur is being stripped of its tightness releasing as time goes on. See Mobilitywod for additional variations including banded distraction (super awesome)
Lax Ball Hip Smash
In a seated position with leg crossed sit on lax ball on affected side. Roll smash and oscillate on the ball around the head of the femur stripping connection points as you roll. Control weight with pressure on your hands as you move into muscular structures including all of the glute musculature working all the way up into your lower back. If you come across a tender spot attempt to apply additional pressure until released and oscillate through it. You may need to swing your knee in various directions to get to deep nastiness. If you are lucky you will find a nice little tender area just superior to your femur on the lateral side that sends an electric sensation down to your lateral knee lean into it and enjoy.
Sidelying Hip Flexor Knee Extensors Smash
In sidelying position get lax ball in the area between the top of the iliac crest (hip bone) and the head of the femur. You will find some tendons that need some attention. As you roll try to separate these tissues releasing the entire area. (Do you hate your lax ball yet?)
Moving to stretching
SUPER QUAD or (KStarr’s Couch Stretch)
In a kneeling position place knee into corner of wall and floor. Working from a quadraped position move to an upright position attempting to fire glute and press hip forward. You may use Proprioceptive Neuromuscular facilitation (PNF ) or periods of pressing forward followed by relaxation (contract /relax) to gain further Range of Motion (ROM) opening the hip angle. You may add hands overhead or rotation away from the knee that is down for additional problem areas of tenderness and restriction
Standing Hip Flexor/ Knee Extensor Hang
Place knee on back of chair, couch or table. Drop knee toward floor hanging toward foot support. Oscillate and maneuver knee so that you get a pulling or stretching occurring at the lateral knee cap. Goal here is to open hip, stretch anterior thigh and distal fascia at knee.
Cross Over ITB
In a standing position cross the affected leg behind the other. Drive hip laterally out to the side utilize reach across and reach overhead to add additional tension to the stretch. (Research has shown overhead reach to add most increase in length to length with stretching)
Partner Y Stretch
Have your patient lie supine bend knee and place foot of non-affected side across the affected side. Place affected leg on your hip and block knee movement with hands at other sides. You will shift your weight to the opposite side manually stretching the ITB of the patient.
Mobilization/ Stretching Summary – Hold all positions and movements 1-3 minutes spending up to 5-8 minutes on really problematic areas. Note – there really is no right or wrong here you will develop a feel for when you have cleared the area. You may not be able to get all of the problems resolved in your first attempt. Spending 10-30 minutes a day either before or after your activity will get you on the road to preventing or fighting ITBS. For ITBS I do like a mobilizing and stretching tissues prior to running. I want as much length in the complex as possible prior to running to avoid any possible impingement in that lateral knee.
3 point Lunge
Multidirectional Lunge – step forward bending back knee to 90 degrees. Step straight forward, Step on a 45 degree angle, step to the side, repeat 6-10 times each leg in each direction for multiple (sets 2-4)
Straight Leg Raise
Lie supine with one knee bent and foot flat on floor. Lock knee into terminal knee extension and lift leg to the level of the bent knee. Repeat this with hip external rotation (rotate foot toward the outside) this will target the VMO and hip adductors 3-4 sets of 10-12 reps
Side lying with effected leg up perform straight leg lift, add internal and external hip rotation (pointing toes toward the ground or ceiling for progression. Perform 3-4 sets of 10-12 reps
On a step or box start with pelvis in neutral position controlling drop of leg until foot comes close to touching ground with straight leg. Actively fire hip abductors moving past neutral hiking hip up perform 4 sets of 12-15 reps
Cross Over Step Up
Stand parallel to stairs or step up box. Cross outside leg up onto step pushing through flat foot control hip motion moving to a hike position. Control slow eccentric movement ad you return crossing back in front of leg. 3-4 sets of 8-12 reps
Weight Shift Step Ups
Place foot flat on step or step up box. Shift weight loading hip and glute on the side you are stepping with. Driving through heel step up and repeat. 3-4 reps of 10-12 each side.
Lateral Band Walks
Place band at Knees or ankles. Shuffle without clicking heels in a controlled manner 10-20 steps in each direction. Repeat 3-4 times with legs straight and knees bent
Quaraped Hip Circles
On all fours lift knee off of ground perform small and large circles with knee. 20 small circles clockwise 20 counterclockwise 20 large clockwise 20 large counter clockwise
Side lying with surgical tubing around knee place heels together and abduct hip opening knees apart 3-4 sets of 10-15 each side
Wall Twists Taps
Standing in line with wall approximately 6-10 inches away rotate trunk away from wall while rotating hips toward wall until tapping wall with hip in a controlled manner. 3-4 sets of 15-20 touches
When am I ready to return to running?
This is a tough one and one that I cannot answer precisely and even struggled with management of answering this in my own recovery. This is very subjective and may lead to a few setbacks or disappointments along the way. Research has shown that the area of friction/compression is reduced during faster running so actually starting back with something faster paced in an interval manner may be of better choice in return to play decisions. Some articles contribute downhill running to ITBS albeit scant anecdotal information we might as well keep the course flat and why not softer surface, track or firm grass early on. There is no measurement or guide as to a return to play protocol but there are some things to look for. We want to make sure that the ITB is flat meaning that any acute swelling or inflammation to the problem area has resolved. Pain with ascending and descending stairs should be resolved prior to any progression into a running program. Any clicking or popping should be non-existent. I would like to see patient’s symptom free for 7-10 days at minimum. Aggressive mobility and strengthening can alleviate symptoms very fast but an aggressive return to running may lead to a restart in the recovery process. Triathletes must also be cognizant of non-running aggravating activities such as pushing off the wall swimming and cycling. Note some can tolerate these activities very well but others this flares their symptoms. Patients should stop immediately at the start of any pain.
As you can see there are so many tissues that may be involved that the determination of the recovery timeline can only vary from individual to individual. Working with a local Athletic Trainer or Physical Therapist should help guide your recovery and return to play decision making plan. They will also have access to specialized equipment such as Alter G and aquatic treadmills which may be beneficial in a return to running protocol. As with anything consistency is key. Working mobility into every workout is essential especially after recovering from a condition such as ITBS. Work hard listen to your body and BEAT THE BAND.
*Thanks to Emily and Travis for modeling for pictures
Best in Health,
Scott Proscia, ATC M.Ed
TriSports Champion Team Member
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