The Injurance Blog Pt7 - Illiotibial Band Syndrome

In addition to our regular Endurance Blog, which covers topics related to endurance coaching and nutrition, we will also be publishing Injurance Blog, which cover common injury topics for endurance athletes.

We work in conjunction with A6 Physiotherapy and Axis Podiatry who contribute their expert advice for each blog post. If you have any questions, post them on THE ENDURANCE STORE Facebook Page, where this blog in posted.

What does the physio say?

Iliotibial band syndrome (also known as IT band syndrome, ITB syndrome, or ITBS) is one of the most common overuse injuries among runners and cyclists. Iliotibial band syndrome can often be felt as a sharp stabbing pain to the outside of the knee, in particular when the knee is bent at about 30 degrees. There have been mixed views on the cause of ITB syndrome. It was initially thought that repetitive bending and extending of the knee caused friction, as the iliotibial band repeatedly passes over the lateral femoral epicondyle (the bump on the outside of the knee) causing it to become inflamed. However further studies of the biomechanics has shown that this is not an accurate cause of symptoms and it is actually due to two biomechanical faults at the hip.

Hip adduction and peak knee internal rotation cause an increase in load at the knee joint (in simple terms this is the thigh and the knee rolling inwards). The Tensor Fascia Lata (TFL) is a fascial sheath on the outside thigh and it works with the Gluteus Medius and Maximus to provide pelvic stability and control the inwards movement of the thigh and knee. A weakness or imbalance in these muscles means that the 'inwards rolling of the knee' is not controlled correctly and this can overload/overwork the TFL/ITB leading to pain and dysfunction. Treatment includes rest, stretches, strengthening and core exercises and soft tissue massage.

If you don’t give yourself a break from running or cycling ITBS can become chronic. While you’re backing off on your mileage, you can cross-train. Swimming, pool running, cycling, and rowing are all great options.

Stretching the TFL/ITB is difficult as not only does it have the tensile strength of soft steel, it also has few stretch receptors, so the person stretching battles to feel the stretch. Most important though, the TFL contracts in weightbearing. This would suggest that you cannot stretch this muscle in a weightbearing position, rendering any attempts to stretch it while standing up totally ineffective. It has thus been suggested that stretching of the TFL/ITB must be in non-weightbearing positions.

Strengthening of the hip abductors/Gluteal muscles has been shown in studies to reduce symptoms of ITB and improve the hip biomechanics. Foam rolling every day for a few minutes on each side is a great way to loosen up your IT band and aid the treatment and management of symptoms. Avoid foam rolling the area that hurts.

Sports such as running and cycling can contribute to symptoms arising if there is altered biomechanics. Cycling is very repetitive; during 1 hour of cycling, a rider may average up to 7,200 pedal revolutions. The smallest amount of misalignment, whether anatomic or equipment related, can lead to dysfunction, impaired performance, and pain.

Altered biomechanics may not just be the result of muscle weakness but anything from bike fit, footwear and even natural gait and foot biomechanics that will have an influence on movement and performance.

What does the podiatrist say?

We've already outlined above that a weakness in the gluteus muscles are the main cause of ITBS. For many runners this has been due to an increase in mileage which they have struggled to tolerate, resulting in a tight iliotibial band. In addition to this when the glute’s fatigue in the latter stages of long runs you lose pelvic / hip stability so the lower limb internally rotates.

I myself suffered this injury after my first marathon when my previous longest run had been a 22 miler. From the opposite end of the kinetic chain foot mechanics can also result in a similar functional alignment issue in the lower limb and contribute to the onset of this injury. My opinion is that it is always best to treat this condition from both top down (hips/glutes) and bottom up (feet) to get the best long term outcome.

This may be something as simple as buying stability shoes if you’ve always ran in neutral shoes. A gaitscan pressure plate analysis with me in the clinic would help to determine if your foot mechanics could be contributing to your symptoms, particularly if physiotherapy and strengthening alone hasn’t completely resolved your symptoms and whether orthoses (insoles) might help in the long term.

Another thing to look out for is a leg length discrepancy. Particularly if your symptoms keep recurring on the one side. There is some evidence that ITBS can be caused by even a subtle difference resulting again in pelvic instability and tightness in the itb band. Orthoses can be made to correct for this and avoid the tightness building up.