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knee pain, knee injuries, Iliotibial band syndrome, ITBS

Knee injuries: Iliotibial band syndrome (ITBS)

This is the right way to look after your iliotibial bands - and help them recover if they go wrong

Do you or any of your athletes experience knee pain during exercise? If so, you're in good company; the knee is probably the most common site of injury in sports.
If your knee pain is lateral (on the outside edge of the knee), then it's quite possible that you may be suffering from 'iliotibial band syndrome' (ITBS). As you may have learned the hard way, ITBS can aggrieve your knee (or knees) enough to drastically curtail or even completely stop your training.
Iliotibial band syndrome has been around since man (and woman) first learned to run, but it wasn't actually described in the medical literature until 1975 (Sports Injuries and Their Treatment, p. 56, J. B. Lippincott Publishers, Philadelphia, USA, 1975). The syndrome is often labelled an overuse injury, but that's a very poor way to describe the origin of the problem, since it implies that the main source of difficulty is excess activity. The truth is that one can be afflicted with iliotibial band syndrome even though one's training regimen is quite meagre; the actual source of iliotibial band disorders is a lack of strength and flexibility in the iliotibial band. In runners, this lack of strength and flexibility is sometimes combined with a perverse fondness for running either on the track or else on crowned roads, as we'll see in a moment.

Definition first
What exactly is the iliotibial band? It's not (sorry) a jazz group whose members tap in time to their music with their lower-leg bones. The central feature of the iliotibial band is a muscle, the tensor fascia lata, which runs down the outside of the thigh just below the hip. Like all muscles, the tensor fascia lata has a band of connective tissue at each end which bind it to bone. The upper band merely ascends vertically a short distance to attach to the top of the hip (thus the name 'ilio-'), but the lower one runs all the way down the side of the thigh before attaching to the lateral side of the tibia, just below the knee (thus the name '-tibial'). Overall, the iliotibial band runs down the outside of the leg from the hip to below the knee, rather like a broad stripe in one's musculotendinous uniform. If you're curious about the muscle's name, the word tensor means 'makes tense,' fascia means 'band,' and lata signifies 'wide,' providing a pretty accurate description of the characteristics of this key muscle.
If you do some digging in any human anatomy book, you'll find that the key action of the tensor fascia lata and its associated bands of connective tissue is supposedly to 'abduct the thigh' (in the patois of human anatomy, 'abduction' means moving a body part away from the midline of the body). At first glance, this 'key action' seems to make sense. If you activate a muscle which originates at the hip and runs down the outside of the leg to just below the knee, won't it simply pull the leg outward, away from the other leg and from the imaginary center line of the body, a bit like flapping a wing?
'Someone who makes a habit of abducting his legs during movement should set his sights on the ballet stage rather than sport'
Hello! Of course it will, but how useful is that motion during sporting activity? In fact, how instrumental is it to everyday life? Someone who makes a habit of abducting his legs during movement should set his sights on the ballet stage, instead of running, soccer, rugby, and other competitions. The real function of the iliotibial band during movement is not to flap the leg outward but to control and decelerate adduction of the upper part of the leg. Adduction is the reverse of abduction; it's the movement of an anatomical structure toward the body's midline. And it's this very motion which requires constant control during sporting activities which involve running.
If that's not exactly clear, picture yourself running across the soccer pitch for a moment, or scooting through a 10-K footrace. Let's say that you have 'toed off' from your left foot, soared through the air for a fraction of a second, and have just landed on your right foot. As you do so, your right foot tends to pronate (the ankle joint rotates in a clockwise direction and the foot rolls to the inside), your tibia rotates in a clockwise direction, and - lo and behold - your femur (the bone in the upper part of your leg) moves inward (goes through adduction). If you can't picture this, see for yourself by going through the mechanics of running in slow motion. The real role of the ITB is to control this adduction - about 90 times per minute per leg as you surge across the soccer field, or a total of 22,000 times during a four-hour marathon. No wonder the iliotibial band sometimes complains!

A rubber duckie in a jacuzzi
What makes things especially tough for the tensor fascia lata is that when the right foot makes contact with the ground and the left leg begins to 'swing through,' there is a natural tendency for the left hip to drop downward temporarily, pulled down by the omnipresent force of gravity. As it does so, the pelvic girdle 'rocks' like a see-saw or a rubber duckie in a jacuzzi bath; the right hip goes up as the left hip goes down. As you probably guessed, since the iliotibial band runs from the hip down to the knee, the upward movement of the right hip stretches the tensor fascia lata and overall iliotibial band at the precise time that it is trying to shorten and control adduction of the right thigh. Ouch - that's eccentric activity! You no doubt are aware that eccentric actions are the ones which can be especialy trauma-provoking to muscle tissues.
Of course, that's one reason why mere stretching of the iliotibial band can never be the complete answer to real or potential iliotibial band troubles. One also has to fortify that pesky tensor fascia lata and its associated connective tissues - making them strong enough to withstand all that relentless eccentric yanking. We'll show you how to buttress your iliotibial bands in a moment, but for now let's make it clear how to tell when you truly have iliotibial band syndrome and not some other condition.

'The discomfort may radiate up and down your leg but, strangely enough, may almost disappear if you stop running'
As mentioned, a key aspect of iliotibial band syndrome is lateral knee tenderness. Very often, the pain won't really hit home until the first 10 or 15 minutes of a workout have been completed ('Iliotibial Band Friction Syndrome in Runners,' American Journal of Sports Medicine, vol. 8, pp. 232-234, 1980). Once it starts, the pain tends to be persistent if you keep running - and frequently gets worse during downhill ambling (or while walking down steps). The discomfort may radiate up and down your leg, but - strangely enough - may almost disappear if you stop running and begin to walk slowly and with short steps.

Try the Noble compression test
If you have iliotibial band syndrome, a unique exam called the Noble compression test will often be positive. As you lie on your back, have your therapist or doctor place his 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 his thumb on your epicondyle, you will actively flex and extend your knee. If maximal pain occurs at about 30 degrees of flexion, it is likely that you have iliotibial band syndrome.
The reason your knee cries out during this test is very simple. When your leg is straight, the iliotibial band lies in front of the epicondyle; as you flex your knee the iliotibial band actually passes over the lateral epicondylar surface. As you repeatedly flex and extend your knee (as you would if you run during your sporting activity), the iliotibial band keeps moving back and forth against the epicondyle; if the iliotibial band is inflamed and swollen, the friction associated with this epicondylar 'rub' can produce quite a bit of pain, especially when your therapist is forcing the iliotibial band to be in close contact with the bone. Similarly, if you have iliotibial band syndrome and you stand with all your weight on your affected leg and flex the knee to about 30 degrees or so, you will probably feel a lot of pain if you apply pressure to the outside of your knee. As an aside, walking stiff-legged with the affected knee locked in place will often eliminate most of the pain, because it keeps the iliotibial band from rubbing back and forth against the epicondyle.
In truth, though, iliotibial band problems don't always occur at the knee. Pain may also be present below the knee, where the iliotibial band actually attaches to the tibia, and discomfort may also occur much higher up - in the tensor fascia lata itself or in its tendinous connection to the hip.

'Having bow legs, excessive leg-muscle tightness, a leg-length discrepancy or pronounced ankle pronation can all increase the risk'
Many athletes will recall an especially intense or prolonged workout just before their iliotibial band problems began. Often, iliotibial band syndrome strikes near the beginning of a competitive season, when athletes are attempting to significantly expand their training loads. Having bow legs, excessive leg-muscle tightness, a leg-length discrepancy, or very pronounced ankle pronation can all increase the risk for iliotibial band syndrome.
The widely accepted way of taking care of iliotibial band syndrome once it arises is certainly less than perfect. Usually, athletes are told to cut back on their intensity and volume of training and to work out only on smooth, non-hilly terrain (if they are runners). Icing and non-steroidal anti-inflammatory medications are recommended to reduce discomfort and inflammation, and athletes with iliotibial band syndrome are cautioned never to try to 'train through' the pain. Obviously, those are decent and logical suggestions, but note that not one of them actually addresses the true cause of iliotibial band syndrome. An athlete who alleviates the symptoms of iliotibial band syndrome with reduced workouts, drugs, icing, and hill phobia and then returns to normal training is often destined for another serious iliotibial band flare-up, with the second episode often worse than the first. Unfortunately, severe cases of iliotibial band syndrome can last for up to six months!

Is stretching any use?
Of course, stretching the iliotibial band is often recommended as an iliotibial band syndrome cure-all, and attempting to improve flexibility is seldom a bad idea. However, it's important that the stretching routine you adopt actually improves the flexibility of the iliotibial band in a functional way. That can hardly be said for the most popular iliotibial band stretches, which bear little resemblance to the body positions commonly associated with exercise. An over-emphasis on stretching may also lull athletes into thinking that they are truly getting at the root of their iliotibial band problems, when in fact their gains in flexibility must be combined with advances in strength in order to make the iliotibial band highly resistant to injury.

The right action to take
To truly strengthen your iliotibial band, carry out the routine described in the next few paragraphs. The only equipment you will need will be a wall or railing for support and some kind of four- to six-inch elevation (an aerobic step or stair step will work fine).
Here's exactly what to do. Stand on the step with your involved leg (the one with the iliotibial band problem), holding onto the rail or wall with the opposite hand for support. Your legs should be fairly straight as you do this.
Now, with both knees locked, lower the opposite, non-involved foot and hip toward the floor. As you do so, your involved hip will move upward somewhat, so that it is actually higher than the non-involved hip. Your involved hip should also move a bit in a lateral direction (toward the outside). This swivel-hip action is crucial to the exercise - and in fact is exactly what happens to the hips during the stance phase of your 'gait cycle' when you run.
Next, attempt to shift most of your body weight to the inside part of the foot of the involved leg. This simulates the natural pronation of the foot which occurs during the stance phase of running, and it also engages and puts tension on your tensor fascia lata and iliotibial band, exactly as it would when you run. Make sure that a fair amount of your body weight is directed through your heel, not just your toes.

Your pelvic girdle as a bowl of milk
You've now come to a crucial part of the exercise: bend your weight-supporting, involved knee slightly (about 10 to 20 degrees), but keep the non-involved foot off the ground or floor. Now, move the involved hip forward about four to six inches, while keeping the involved heel in contact with the step and your weight on the inside of your involved foot. As you do this, all of the action should be at the hip! Your knee angle should stay about the same throughout the exercise (don't try to rock forward at the knee - do it from the hip). This action is what we might call a 'pelvic tilt.' If you think of your pelvic girdle as a bowl of milk, your 'bowl' is rocking backward (e. g., the bottom of the bowl is coming up and toward the front as the top of the bowl goes back and slightly downward). As your involved hip moves forward, your upper body should move backward. Very key points: as your involved hip moves forward, make sure that it stays in a lateral position (for example, if it's your left hip, your left hip should remain shifted to the left), and also be certain that your involved hip is higher than your non-involved one.
After you've moved your hip forward, move it straight backward - making sure it goes back four to six inches beyond the straight-up, starting position (the total hip-movement distance in this exercise is around eight to 12 inches, four to six inches toward the front and four to six inches back). As your hip moves backward, your upper body will tend to bend forward.

'Most athletes think that the key action of running is swinging the foot back and forth around the 'anchor point' of the hip'
This overall action may seem strange to you, especially when you realize that in effect your hip is swinging back and forth over your foot in two different planes of motion - front to back (the sagittal plane) and also sideways (the frontal plane). Most athletes envision the biomechanics of running quite differently - and tend to think that the key action during running is the swinging of the foot back and forth around the 'anchor point' of the hip. However, the truth is that when the foot is on the ground the foot is the anchor point, and the hip essentially rotates around the foot, not vice-versa. It's this action which puts mega-stress on the iliotibial band, and that's why we favour this exercise, which mimics the hip rotation associated with running and maximally fortifies your iliotibial bands.
As you do the exercise, you should feel the burn - or if not the burn at least some pretty heavy-duty pulling and stress - up toward the side of your hip. If you don't feel much going on, go back to the basic position and try again, making sure that your involved hip ends up in a lateral position and higher than the other hip - and also making certain that your weight is shifted to the inside of the involved foot. As your weight shifts to the inside of the foot and your hip moves laterally, your thigh is adducted, exactly as it is when you run, and your iliotibial band must work hard to control this adduction as your hip moves back and forth.

Now bring the arm in
Once you get really good, you can do an advanced version of the exercise, getting the arm on the involved side of the body into the act. First, simply move the involved arm laterally and forward as your hips swing forward. Then, try moving the involved arm forward and over the front of your body as your hips begin to swing forward. Of course, if one of your iliotibial bands is red-hot right now, you'll have to wait a bit to try the redeeming exercise. Otherwise, the cure might have a little bite of its own.
If you are currently on the road to recovery from an iliotibial band setback, do the exercise as your symptoms allow, being careful not to overextend your iliotibial bands (start with just a few reps of the exercise). If you're basically symptom-free now but have had trouble with iliotibial band syndrome in the past, you can be fairly aggressive with the exercise. Start with 10 reps per day on each leg, and gradually build up to a set of 20 to 30 reps - carried out at two different times during the day (make sure you carry out a brief warm-up in each case). If you do so, your iliotibial band problems will become distant memories.
If you've never suffered from the agonies of iliotibial band syndrome, do 10 to 15 reps of the exercise two to three times per week, anyway. And always use the exercise as an injury prophylactic during the weeks leading up to a major increase in training (remember that iliotibial band syndrome is particularly likely to occur when the volume and/or intensity of training increase). For example, if you are in a base period of training but are planning to sharply increase your training time, do at least one set of 15 reps twice per day on each leg during the last three weeks before your training volume begins to rise significantly. The same would apply to a shift from regular training to high-intensity workouts.
The unique exertion will keep you out of iliotibial band trouble in the future; as it bolsters your iliotibial bands, it will enhance your ability to control the adduction and rotation of your thigh bone during your sporting activity, reducing both fatigue and muscle soreness. As you gain greater control of your hip and thigh, there's also a good chance that your efficiency of movement (running economy) will improve. Remember, too, that you mustn't carry out the exercise only on the leg which has given (or is giving) you trouble. To balance your strength properly, do approximately the same number of reps on each leg, even though one leg may be trouble-free.

Get off the crown and on to the shoulder
If you happen to be a runner and you do some of your training on crowned roads, watch out! You are at increased risk for iliotibial band syndrome, compared to the runner who prefers flat surfaces, and your iliotibial band troubles are likely to strike on the 'down' leg, the one positioned toward the outside of the road. That's why runners who run with the traffic tend to have iliotibial band troubles in their right leg; those who run against traffic get the flare-ups in their left. The reason for this, of course, is that the outside foot and leg are moving downward at a faster speed when they strike the pavement, compared to the inside foot and leg, because they have fallen a slightly greater distance. It's as though the outside leg is always running downhill. Thus, the total force on the outside leg will be greater, and there will be an increased need for 'thigh deceleration' by the tensor fascia lata and its associated iliotibial band. The tensor fascia lata will be shortening and generating more force at the same time that the pull on it is unusually great. That's a recipe for injury! It's best to get off the crown and run on the usually flatter shoulder - or else to choose a different, non-sloped location for your workouts.

'When a person runs on a curve to the left, he/she will compensate for the outward-pushing centrifugal force by leaning slightly to the left. The faster the run, the greater the lean'

It is an unwritten law of the universe that runners must run on a track counter-clockwise, rather than clockwise. This means that for the person who trains excessively on the track, iliotibial band syndrome will almost always strike in the left (inside) leg, because the left tensor fascia lata and its bands must control a greater deceleration of adduction than the right (outside) hip. When a person runs on a curve to the left, he/she will compensate for the outward-pushing centrifugal force by leaning slightly to the left. The faster they run, the greater the lean must be (that's why very fast track sessions pose an increased risk for iliotibial band syndrome). You see the same thing in 'flop' high-jumpers' approach runs: they run fast and lean far to the inside - toward the bar. This lean with the upper torso can drastically change what happens biomechanically. As you lean into a left curve and your left foot hits the ground, pronation is exaggerated compared to running straight ahead, since the left foot tends to land more toward the outside and thus must roll to the inside to a greater extent than usual (there is more frontal-plane, side-to-side movement than usually occurs). As this happens, the left thigh accelerates inward (adducts) to a greater extent than normal, creating a need for greater deceleration than usual by the iliotibial band and stressing the iliotibial band considerably more, compared to running straight ahead. If you must run on the track, it makes sense to alternate back and forth between clockwise and anti-clockwise intervals.

Two unequal legs
Having a leg-length discrepancy also increases the risk of iliotibial band syndrome. When two legs are unequal in length, the shorter leg receives greater stress in much the same way that the outside leg takes in more force during running on a crowned road. The momentum and ground-reaction forces are higher for the shorter leg because that leg falls a greater distance before the foot makes impact with the ground. This increases ankle pronation and thigh-bone adduction - and thus the stress placed on the iliotibial band.
Women should suffer from iliotibial band syndrome more frequently than men, since their wider hips promote greater thigh-bone adduction and thus greater stress on the iliotibial bands. However, the research doesn't support this idea - and in fact suggests that men may actually be plagued by iliotibial band syndrome more often, perhaps because of greater muscle tightness and inflexibility, not to mention a heavier reliance on 'gonzo' training and a trend toward more sudden spikes in training volume.
Speaking of inflexibility, it's important to stress once again that traditional stretches may not work very well at preventing or relieving iliotibial band syndrome. In one classic stretch, assuming the right leg is the afflicted one, the left leg is crossed over in front of the right, and the upper body is inclined to the right, placing a fair amount of stretch on the right iliotibial band. One problem with this venerable move is that it is not very functional (it doesn't replicate a key movement pattern), but the other key drawback is that it does not strengthen or increase the resiliency of the iliotibial band. It gives the iliotibial band a little bit of a pull, but the tensor fascia lata and its associated bands don't have to control a single thing. The best exercises always simultaneously bolster dynamic flexibility and strength, and our choice certainly does that!
If you now have a severe case of iliotibial band syndrome, try to stay in shape by swimming and/or aquarunning: These activities will keep you fit without aggravating your condition. Bicycling and stair climbing are usually 'out' if you have iliotibial band syndrome, because they can produce considerable rubbing of an inflamed iliotibial band on the outer edge of the femur, potentially retarding recovery.

Owen Anderson

knee pain, knee injuries, Iliotibial band syndrome, ITBS