If you run or plan on starting to run, you need to know about iliotibial band syndrome (ITBS). It can be an absolute nightmare for any runner. In this article we will cover how you can identify if you have it, how and why it occurs and of course, how to fix it.
It is essentially an irritation to the outside of the knee as a result of increased friction/compression as the band rubs over the femoral condyle (bone) as the knee bends and straightens during the motion of running (or cycling/similar movement). Thus, causing inflammation and pain to the structures involved.
To completely understand this article, it is important you have some basic anatomy knowledge of the ITB and its surrounding structures
Firstly, the ITB IS NOT a muscle, it is a strong band of thick connective tissue about 1 inch wide running down the outside of the thigh.
At the hip, it attaches to a muscle called the TFL (tensor fascia lata) at the knobbly part on the outer most point of the hip
The bottom attachment is on the outside of the knee - predominantly to the tibia bone (see diagram)
As the above information indicates, the ITB crosses the hip and the knee joint and plays an important role in stabilising both joints.
Let me emphasise, the ITB is connective tissue not muscle…
Feel it. Bend and straighten your knee with your hand above your knee on the outside of your thigh. It feels like a thick rubber band.
Do I have it?
The initial onset of ITBS is likely to come on towards the end of your run or bike ride and generally the pain will stick around after you finish too. Most people that suffer from ITBS get it when they are either, just getting into running for the first time, after a long break or when they have increased their training faster than their body can handle. It may be that you decide to try and push your limits by running a 26km run after you’ve just been training under 10kms. Or you might have a race coming up and think you should test out race pace and increase your intensity significantly… Whatever it might be, the underlying similarity between all of these examples is that none of it was gradual. Biomechanics and strength went out the window and your ITB became problematic as a result.
Lateral knee pain
Pain can radiate up the outside of the thigh
Pain worse when you poke with your finger
Stiff and sore in the mornings but eases with some walking
Potential differential dx:
Lateral meniscal injury (inside the knee joint)
Quadiceps or patella tendon injury
Distal hamstring (biceps femoris) Tendinopathy
Patellofemoral joint pain syndrome (pain from under the kneecap)
Treating the symptoms of ITBS:
(In order of effectiveness - in my opinion)
Rest: Your best friend in the early stages of trying to reduce pain.
Ice: 15 minutes, every hour following exercise or when painful/inflammed
Anti-inflammatories: Optional. Can be really helpful but please get medical advice first.
Massage/foam roller: Quadricep and ITB massage and foam rolling can help improve symptoms
Taping: Optional - may or may not help symptoms. Depends on taping technique and the parson.
Causes and management for ITBS:
Many therapists and patients/people believe the ITB is painful as a result of it just miraculously tightening up… NO! Please understand the ITB tightening up isn’t the sole cause of why this condition comes about. There are always underlying reasons for the tightness and pain. Here they are:
Change in training load/activity:
Doing a new activity or dramatically increasing the intensity/duration of your normal activity is the most common cause for onset of iliotibial band syndrome. A swimmer who hasn't been for a run in 5 months decided they can handle a 5km parkrun to attempt a new PB is a typical example of this. Coming from a sport with basically no vertical load through his joints and muscles to a high intensity run - recipe for ITBS injury.
Too much, too soon. Running is a fatiguing activity so when some of our muscles start to fatigue other structures have to work harder to
Treatment/solution to avoid injury:
As we have discussed in previous articles, our body needs time to adapt to changes. Start by waking up the new structures that will be working hard, in the case of running this is the lower limb muscles and joints. A walk/jog is a perfect first step. Then progress to a slow consistent jog of 2-3 km and go from there.
The same goes for an experienced runner. Any changes in training, such as distance, pace, hills, surface and footwear, can lead to a change in how the muscles function and lead to fatigue. This then leads to a possible change in biomechanics which stresses tissue in different ways to then normal running efforts.
There is now an abundance of research looking into how hip control and its relationship to overall leg and knee alignment. We know for a fact that if a runner has weakness around the hip that it is more than likely they will fatigue quicker when running and expose their knee to altered alignment and potential pain. The ITB is a stabiliser of the hip and knee as it crosses both joints so when weakness is present it has to work on overdrive to help with control and alignment leading to increased tightness. This is usually when it gets to a tipping point and the tightness can create the increased friction around the outside of the knee. The quads have also been found to be important in knee control, so again, weakness here can lead to similar issues.
A personalised exercise program created by a physiotherapist which starts off with you loading the glutes and releasing the quads/ITB. Followed by progressive loading to the quads and other knee related muscle groups to build necessary strength to avoid the pain and tension in the ITB coming back. A special mention needs to go to biomechanics here as the glutes are generally the key fault in ITBS so assessment of loading and running technique can also be very effective to correct this area.
Biomechanics and movement control are a summary of the whole picture. A lot of different aspects come into play here. If you have muscle weakness, incorrect footwear, muscle stiffness or pain, your biomechanics is likely to be altered. Other things such as leg length discrepancies and previous/current injuries will also need to be considered.
Biomechanics is the summary of how you move when you run. Let's take over pronation at the foot as an example. If you over-pronate when you land during your running motion, chances are that your hip also comes into adduction (knee angles inwards). Due to this alignment alteration the ITB has a lot of work to do to try and maintain some form of alignment in the knee but this creates more tightness and possibly leads to pain in the for of ITB friction syndrome.
The other most common example is weakness at the glute which creates more hip adduction and results in the same end result.
Getting your running analysed can be a helpful tool here or even discuss the problem or pain you are getting with a physio that knows about running injuries and they can help identify the causes of you you pain and help make a plan for correcting any biomechanical faults to fix the problem and stop the pain coming back.
ITBS is a frustrating condition but not a bad one to have in the grand scheme of things. No physical structural damage and not overly difficult to fix if you get the right opinions as early as you can in the injury course. There is ALWAYS and underlying cause for ITBS. Once identified and corrected, you have the tools to never suffer from this condition again.
Keep running and stay safe.