Iliotibial Band Syndrome (ITBS) or Iliotibial Band Friction Syndrome (ITBFS) is a common overuse injury for runners but can also develop in cyclists and other athletes. 5-12% of runners experience ITBS.1 ITBS is characterized by pain and swelling on the outside of the knee joint near the lateral femoral epicondyle (bony bump on outside of knee). It is this lateral epicondyle that the IT Band can rub against, causing this pain and swelling. Pain is typically reproduced when the knee extends (straightens) from 90 degrees to 30 degrees, which is the range of motion where the IT band gets most compressed into the lateral epicondyle. This is known as the Noble Compression Test.2 Movement within this range also occurs during every running stride or cycling pedal stroke, so if the IT band begins to rub or compress into the lateral epicondyle during this motion, it will continue again and again, only worsening as the IT band gets more irritated and inflamed.
There are two main explanations for the cause of ITBS which both have some merit and both are probably at play to some degree in most ITBS cases. The first explanation is that there is extra compression of the IT band where it inserts on the outside of the tibia (shin bone), just below the lateral epicondyle of the knee. This area is plentiful with fat, blood vessels, nerves, etc. so continuous compression could irritate and inflame this area. The second explanation is that the IT Band becomes inflamed as it slides over the lateral epicondyle as the knee bends and straightens.3 There is essentially friction between the IT band and lateral epicondyle, hence this injury sometimes being referred to as Iliotibial Band Friction Syndrome. Whether it is compression or friction or a combination of the two, the result is thickening and deformation of this distal part of the IT band. This contributes to the pain and irritation over the outside of the knee especially with the repetitive movements of running and cycling.
Studies have shown that weak hip abductor muscles (gluteus medius and upper fibers of gluteus maximus aka outer buttocks muscles) are common in runners with ITBS.2 Increased running mileage is also associated with ITBS.4 IT band strain occurs during the initial loading and deceleration stance phases of the running stride, which is where the affected leg lands and begins to absorb the impact of landing, and the knee begins to flex (bend). A runner with ITBS tends to run with their knee caving inward on the affected side which is often due to weakness of the hip abductors and external rotators. Another compensation seen in running gait for runners with ITBS, is ipsilateral trunk flexion (leaning the torso towards the affected leg) which would help reduce tension and strain on the IT band. A pelvic drop on the opposite side is often also seen, i.e. the hip of the leg that’s in the air drops lower than the other hip upon landing during running. A cross-over gait pattern can also increase IT band strain.5 To visualize this running gait, picture a line on the ground that you are running along. With a cross-over gait both feet would land on the line or on the opposite side of it, with both your feet in essence crossing over the line, and your opposite foot.
Now that we have a better understanding of what ITBS is, how to identify it, and some potential causes of it, let’s look at some potential treatments for it. The first treatments to discuss are soft tissue techniques (i.e., trigger point release, dry needling, soft-tissue mobilization, etc.). The IT band is a band of fascia that runs down the outside of your leg from your hip to just below your knee. Along the way the IT band connects to several muscles including the biceps femoris (a hamstring muscle), Vastus Lateralis, (the outermost quadriceps muscle), Tensor Fascia Latae (TFL), and gluteus medius and maximus (outermost buttocks muscles). Thus, performing soft tissue techniques to any or all of these muscles could be beneficial in the treatment of ITBS. One way to do this on your own is with foam rolling. Below is a video showing foam rolling techniques for all lower body muscle groups including those mentioned above.
Due to the deformation and thickening of the distal (bottom-most) portion of the IT band on the outside of the knee, performing soft tissue techniques to this area could also be beneficial in treating ITBS. Instrument assisted soft tissue mobilizations (IASTM) have shown some benefit for this.6
Stretches involving the IT band and surrounding musculature have also been seen to offer a benefit, especially with adding overhead arm abduction with the stretch (pictured below).7
Strengthening the hip abductors, hip external rotators and gluteus maximus (outside of hip and buttocks) have all been shown to be helpful in treatment of ITBS. Research suggests a three-phase strengthening program to address these muscle groups when treating ITBS. Phase 1 of strengthening includes open chain (feet not on ground) exercises aimed at activating the problematic muscles. The exercises in this phase include the clamshell, mule kick (with knee straight and bent), single-leg bridge, and lateral band walk exercises which are shown in the pictures and videos below.
Phase 2 is made up of closed chain (feet on ground) exercises and can be initiated if the phase 2 exercises involve no or minimal pain (less or equal to a 3 rating on a 10-point scale). These phase 2 exercises include single leg stance on the uninvolved (non-injured) leg while the injured leg is abducting against a wall, hip hikes on involved (injured) side, single leg squats, and single leg deadlift which are shown in the pictures and videos below.
The above strengthening exercises when done concurrently with movement retraining, including running, can be even more beneficial when you are ready for it.8 This brings us to phase 3, which is plyometrics and running, and can be progressed to if phase 2 can performed comfortably with minimal to no knee pain. Phase 3 begins with two-legged landing when dropping off a step. Do this in front of a mirror to see, and correct for, your knee(s) caving inward. You should also focus on landing softly which you will know if you are doing if you land quietly. If your landing is loud, then try to re-train yourself to land quietly. This can be progressed to single leg landings when two-legged lands are performed well. Further progressions are single leg side to side hops and then multi-directional hops and agility ladder drills. A mirror should be used to watch and correct for knees caving in or hips dropping to either side. The last piece of the puzzle would be running in front of a mirror correcting for the same faulty movements.
This movement retraining involves progressing from two-legged jumping to single leg jumping to running with a mirror providing a visual cue to not let the knee(s) cave inward and the audible cue of trying to land as quietly as possible. Increasing running cadence (strides per minute) by 5-10% has also been shown to decrease how much and how fast the knee(s) caves in during running which can potentially decrease the tension placed through the IT band.9 Some case studies have also shown success with this in treating ITBS in runners.10 Furthermore, this increased cadence has been shown not to decrease running efficiency in runners which can often be a fear of making such a change.11
Lastly NSAID’s such as ibuprofen have shown to decrease pain felt with ITBS in the short term.12 Corticosteroid injections, ice and rest have also been shown to decrease pain associated with ITBS during and acute onset (recent start of pain/inflammation).13 The takeaway here is at the onset of ITBS you should treat with ice and rest, and anti-inflammatories, if you are medially cleared to take them. Always consult your doctor before doing so if uncertain. Depending on how irritated and inflamed your IT band is, you may not be able to even begin phase 1 strengthening above for the first 7-14 days and should focus on these methods to reduce inflammation first.
Conclusions
First identify that you have ITBS which usually presents as pain and swelling over the outside of the knee which occurs when bending and straightening the knee especially in a repetitive nature such as during running or cycling. NSAIDS, rest, and ice are the initial treatments to reduce the inflammation. When able to, start performing soft tissue techniques such as foam rolling, stretching, and the three phase strengthening program laid out above.
So hopefully, you have a clearer picture of how to identify ITBS, why it happens, and a structured plan on how to address it. Examples of the stretches and strengthening exercises were included in this article. For a complete strength training plan which includes stretching routines and strength training that addresses these and other problem areas for endurance athletes, see Endurance Strong’s strength training plans. As far as correcting training errors, one good approach would be following a proper training plan created by a quality coach, such as the training plans you can find from Endurance Strong. See all our strength training and endurance training plans here. Hopefully, this gives you a start in your road to recovery or some good information on how to prevent ITBS in the first place.
Note: Any of the above treatments or exercises you try, shouldn’t increase your pain levels especially in the knee joint other than typical discomfort in muscles one would feel with stretching, strengthening exercises, and soft tissue techniques. If you are unsure of this difference, then a clinician such as a physical therapist can help. None of the information in this article should take the place of medical advice and only be done with consent of a medical professional.
References
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