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ITBS is a common cause of knee pain in runners, bicyclists, martial artists
and dancers. It is characterized by sharp or burning pain on the outside
(lateral) side of the knee, thigh or buttocks.
What is the ITB and what does it do?
The ITB is a wide, flat ligament like structure that runs down the side of
the thigh from the side of the hip (iliac crest) to the lateral part of the
bone just below the knee (tibia). It provides stability to the outside of
the knee and helps control inward motion of the thigh. The ITB is not
attached to bone as it passes between the femur and the tibia. This allows
the ITB to move forward and backward with knee flexion and extension.
The function of the ITB is to slow down or decelerate adduction
(movement toward the midline of the body) of the thigh during walking or
running. In other words, the ITB stabilizes the thigh and prevents
unnecessary side-to-side motion. "This adduction occurs about 90 times
per minute per leg as you run and almost 22,000 times during a four-hour
marathon! No wonder the ITB sometimes complains!" (1)
What causes ITBS?
ITBS is believed to result from recurrent friction of the iliotibial band
(ITB) over the bony prominence just above the lateral portion of the knee.
With ITBS, the bursa often become inflamed, causing a clicking sensation as
the knee flexes and extends. Over time, inflammation actually diminishes
and scar tissue (adhesions) develops from the repetitive tearing of the
fibers of the ITB. Because of the build-up of adhesions, the ITB becomes
congested and tight with greatly decreased blood flow. This causes a
further build-up of congestion and the process continues.
General causes
1. Leg length differences
2. Foot structure: excessive pronation (flat feet)
3. Excessive shoe breakdown (particularly it the outside of the heel)
and poor shoe fit.
4. Training intensity errors - increasing mileage or intensity too fast
5. Muscle imbalances - quads versus hamstrings, hip abductor weakness
6. Run/gait style factors - e.g. bow-leggedness, knock knees, etc
Bicycling (2)
1. Poor cleat position cause ITBS when cleats are excessively rotated
internally.
2. Incorrect saddle height: the saddle height should be set so that your
legs are almost fully extended (about a 15 degree angle at the knee) at
the bottom of each pedal stroke.
3. Saddle positioned too far back causes a tightening of the ITB.
4. High gearing ratios and excessive hill work cause overstraining of the
ITB.
Running (2)
1. Running on slanted surfaces (runners who run with the traffic tend to
have ITB troubles in their right thigh because that leg must travel a greater
distance each time it hits the ground) or run track (the counterclockwise
running causes ITBS in the left thigh because the ITB must control a greater
deceleration of adduction in the left hip.
2. Too much downhill running.
How to tell if you have ITBS
The key aspect of ITBS is lateral knee pain. Runners often note that they
start out running pain free but develop symptoms after a reproducible time
or distance. Early on, symptoms subside shortly after a run, but return with
the next run. If ITBS progresses, pain can persist even during walking,
particularly when the patient walks up and down stairs. "If you have ITBS,
a unique examination called the Noble compression test will often cause pain.
As you lie on your back, your doctor will place his or her thumb over the
lateral epicondyle of your troubled leg (the lateral epicondyle is the hard
knob on the bottom, outside part of your thigh bone). With the thumb on
your epicondyle, you will actively flex (bend) and extend your knee. If
maximal pain occurs at about 30 degrees of knee flexion, you probably have
ITBS."(1)
"The differential diagnosis for lateral knee pain includes primary
myofascial pain, patellofemoral stress syndrome, early degenerative joint
disease, lateral meniscal pathology, superior tibiofibular joint sprain,
popliteal or biceps femoris tendinitis, common peroneal nerve injury, and
referred pain from the lumbar spine. In most patients, these conditions can
easily be ruled out with a careful history and physical examination." (3)
Treatment
Initially, any inflammation of the ITB must be arrested. This can be done
with over-the-counter (OTC) anti-infammatories, but I certainly prefer more
natural remedies like bromelain and arnica (see my article
Nutrients for Healing
for more suggestions). Ice also is important; ice the ITB at
least twice per day for 15 minutes. Once the inflammation is addressed
the cause of the ITBS must be corrected. Primary muscles used in any
activity repetitively require specific attention. If not, they will slowly
tighten due to an accumulation of unwanted toxins and a reduction of normal
blood flow (nutrition and oxygen) to the muscle. This is why techniques like
Active Release
and Graston
are so effective with ITBS. Both these techniques remove
the scar tissue restoring the proper blood flow and oxygenation to the
tissue. None of the OTC anti-inflammatories do this! If the scar tissue
is not removed the problem will never really be corrected. Areas to be
treated must include not only the ITB, but the TFL, gluteus minimus,
piriformis, vastus lateralis, biceps femoris, soleus and plantar surface
of the foot.
Cutting back on the intensity and volume of training is critical. STOPPING
for a bit (1-2 weeks) while getting treatment may be necessary. Do NOT
train through the pain! A proper warm-up and cool down is necessary.
Warming up and cooling down with the Stick is wonderful. Stretching is
part of these. Gentle stretching is critical when recovering- do not
overstretch! A gentle pulling should be felt when stretching. There
are many ways to stretch the ITB - see the Wharton's Stretch Book and
Facilitated Stretching for suggestions. Other muscles which must be
stretched included the calf (gastrocnemius and soleus), hamstrings,
quadriceps, hip flexors and gluteal muscles.
Correcting structural imbalances and any equipment or training errors is
crucial. For leg length discrepancies a heel lift may be necessary.
For pronation orthoticsshould be casted. Any muscle imbalances must be
corrected (we offer a unique
personal training program which will assess and
correct these issues). See my article See
Strength Training for Runners for
ideas. Keep a training diary. You will be amazed at what you discover
by keeping a diary.
When attempting to return to regular activity, remember REST: Resume Exercise
Below the Soreness Threshold. Gradually increase the frequency and
intensity of your training. It may be helpful to think about injuries in
4 stages:
Stage 1: You are able to exercise, but you have pain afterwards.
Start icing, stretching and making the aforementioned corrections.
If you get to Stage 3 or 4, you need treatment.
Stage 2: You are able to exercise, but you have pain during exercise.
This pain does not affect the quality or quantity of your exercise,
e.g. if you run, the pain does not affect how fast or far you run.
Start icing, stretching and making the aforementioned corrections.
If you get to Stage 3 or 4, you need treatment.
Stage 3: You have pain during exercise and it affects your performance.
e.g. If you run, the pain slows you down or causes you to shorten your
distance, or both. You need treatment!
Stage 4: You are unable to exercise at all due to pain -
you need treatment!
References and suggested reading:
1
Sports Injury Bulletin
2
Active Release Techniques
3
Physician and Sports Medicine
Michael Fredericson, MD; Marc Guillet, PT, ATC; Len DeBenedictis, MS, CMT
Quick Solutions for Iliotibial Band Syndrome, THE PHYSICIAN AND
SPORTSMEDICINE - VOL 28 - NO. 2 - FEBRUARY 2000.
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ILIO-TIBIAL BAND SYNDROME (ITBS)