Iliotibial band syndrome

Typically, there will be problems with the biomechanics of the lower limb. Invariably with runners. dynamic muscle control (control of movement patterns) around the hip and pelvic girdle is an issue, and often the eccentric control (where muscles are required to lengthen under loading or tension) of the quadriceps group also. This manifests as what we term muscle imbalance, and is the result of repetitive movements in a poor biomechanical pattern. The good news here however, is that if you correct these problems your running technique will undoubtedly improve as the kinetic chain will absorb the forces down the lower limb more efficiently.

Text by: Physiotherapist / Susannah Evans MCSP MSc Sports and Exercise Rehabilitation


Iliotibial band syndrome (ITB) is a common problem particularly with runners.

Symptoms

There will usually be tightness and discomfort/pain at the side of the knee, which may extend up the side of the thigh. In more long standing cases pain may radiate up as far as the hip.

Typically, there will be problems with the biomechanics of the lower limb. Invariably with runners. dynamic muscle control (control of movement patterns) around the hip and pelvic girdle is an issue, and often the eccentric control (where muscles are required to lengthen under loading or tension) of the quadriceps group also. This manifests as what we term muscle imbalance, and is the result of repetitive movements in a poor biomechanical pattern. The good news here however, is that if you correct these problems your running technique will undoubtedly improve as the kinetic chain will absorb the forces down the lower limb more efficiently.

Often there is clicking at the outside of the knee, where the tendon snaps over the femoral condyle, at the bottom end of your femur. Pain usually is no better after a period of rest and return to activity. Further investigations are not usually needed, unless symptoms fail to resolve with conservative management. There are injection and surgical options available for this problem, however neither should be considered until conservative therapy interventions have been tried.

 

Pathophysiology

There are two main theories. The first school of thought is that symptoms arise due to friction of the tendon over the femoral condyle causing irritation and inflammation of the distal portion of the ITB, or pain from the bursa (fat pad) underlying the ITB which becomes compressed and irritated underneath

Risk factors include, but are not limited to – poor biomechanics, weak hip stability/gluts, high running mileage, pre-existing ITB tightness, time spent walking or running on a track ….

People who repeatedly flex and extend the knee will likely be at higher risk of ITB injury, due to maximum friction of ITB over the femoral condyle which occurs between 20-30 deg knee flexion, this makes it even more important to control the limb well through the ground contact and push off phase of the gait cycle. Anything which increases overload at this range of motion is likely to exacerbate the problem.

in the acute phase a period of rest or ‘modified activity’ is imperative to the recovery process. Low impact alternatives to running in order maintain a base level of fitness include cycling (although this may not be comfortable), swimming, or pool running.

Usually ITB problems will be due to overuse, and some element/s of poor biomechanics. As a result of these biomechanical faults certain areas will become tight and others relatively weaker.

Runners are often told that they have ‘weak gluts’, one runner even told me that a therapist told him he had a ‘saggy bottom’?! Quite what he gained from hearing that I am not sure, aside from feeling a lot more self-conscious in his running shorts. Actually his bottom objectively looked quite normal, however on specific resisted testing there were, as expected, clear problems with muscle activation at the glut med and also issues with pelvic stability through the running cycle, despite being absolutely fine in standing and walking in terms of symptomatic onset.

 

Treatment

A ‘3 phase’ approach to treatment usually works best:

  1. Reduce pain and inflammation
  2. Massage and stretching
  3. Strengthening

Rest from running is important to let the irritation calm down, this is not to say stop all exercise completely. However, in most cases the sensible thing to do is to be guided by pain. If it hurts the site of your injury it is probably not helpful. Of course, there are good pains and bad pains but if in doubt it is best to seek advice about the problem rather than pushing through the pain and increasing the likelihood of developing a chronic injury.

Ice can be helpful. Personally I prefer to go for a combination of ice and heat therapy as I have found this more effective. The aim of this conventional self-therapy is to increase blood flow and thus provide oxygen and nutrients to the injured site, settling irritation and aiding mobility. Adding the heat in between the cold may facilitate this effect in a speedier manner.

If you are at acute stage injury (esp first 48 hours or with pain soon post exercise) and/or there is obvious swelling go for just cold therapy i.e. ice applied for no longer than 20 mins at a time. I usually recommend 10 min on – 10 off – 10 on again, as this appears to create the best flushing action of circulation from the research I have read. It is important to note though, that there is no clear consensus on what is best in terms of length for ice application. Heat has been advocated for more chronic injuries, muscle spasm and tendinopathies. This is likely more effective as they are primarily areas of ischaemia and so the vascontritive effects of ice may not be as helpful.

Massage, or myofascial release can help to correct muscle imbalances, particularly at the ITB/quadriceps interface.

All runners should use a foam roller. It is a fantastic piece of equipment. So simple and yet so effective. You can massage out through the ITB interfaces at the lateral quads and hamstrings, as well as working through those muscle groups individually and the calf muscles too! This can be extremely helpful to regain normal mobility within the soft tissues, and is a useful recovery and injury prevention tool too. Using a tennis ball, TP ball, or an Orb ball can also be helpful, especially for the gluteal muscles.

So, to address the muscle imbalances and biomechanical issues. In simple terms, stretching out and mobilising the tight bits and strengthening the weaker ones. Always best to try and keep it functional and aim the exercises towards the end goal, in this case running…

Gluts strengthening and conditioning for runners:

Exercises lying down for early stage rehab – side lifts, clam, open gait, bridge

  • Clam
  • Bridge
  • Move on to these more functional based exercises as soon as possible
  • Single leg dips
  • Side steps shuffle walk
  • Hip hikes
  • Running man/single leg squat backs
  • Deadlifts and squats, lunges, single leg squats
  • All useful as on-going conditioning exercises…Most of these exercises can be found at this Runners World link:

Good luck!

bridge

 

clap

 

Iliotibial

Further info/reading:
http://www.humankinetics.com/excerpts/excerpts/how-to-use-heat-and-cold-to-treat-athletic-injuries
Beals, C., & Flanigan, D. (2013). A review of treatments for iliotibial band syndrome in the athletic population. Journal of sports medicine, 2013.
Meardon, S. A., Campbell, S., & Derrick, T. R. (2012). Step width alters iliotibial band strain during running. Sports Biomechanics, 11(4), 464-472.
Aderem, J., & Louw, Q. A. (2015). Biomechanical risk factors associated with iliotibial band syndrome in runners: a systematic review. BMC musculoskeletal disorders, 16(1), 1.