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Injury spotlight: iliotibial band syndrome.

Every so often it's useful to review some of the most common running injuries, as the same questions to the ARA Clinic seem to surface again and again. Here, certified strength and conditioning specialist Dr. Paul Glodzik examines one among the most recurring of running injuries, iliotibial band syndrome (ITBS). 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 lateral side (outside) of the knee, thigh or buttocks.

What is the iliotibial band and what does it do?

The iliotibial band (ITB) is a wide, flat ligament-like structure that runs down the side of the thigh from the side of the iliac crest (hip) to the patella (knee cap), tibia (shin bone) and biceps femoris tendon (part of the hamstrings). It provides stability to the outside of the knee and helps control inward motion of the thigh. 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. It's not surprising, then, that this ligament can become overstressed, strained, tight, or inflammed.

What causes ITBS?

It was previously believed that the ITB would rub against the lateral condyle of the femur (the outside edge of the thigh bone). Newer research has shown that this is not the case. However, pain in the lateral epicondyle (the hard knob at the bottom of the outside thigh bone) when pressure is manually administered and the knee is flexed at 30 degrees, is indeed a symptom of ITBS. It was also previously thought that the ITB was rubbing against a bursa (fluid filled sac) and cause pain, but most individuals do not actually have a bursa at this location. There is, though, a highly vascular fat pad located beneath the ITB at this location. When the knee is flexed, the tibia rotates internally. If there is no compensating external rotation of the femur, the ITB increases compressive forces on the lateral aspect of the knee. The increased compressive force prevents blood flow from passing through the fat pad. With the decreased blood flow, inflammation occurs within the fat pad, causing pain. The pain is usually at its highest intensity when the knee is flexed at 30 degrees.

How do you know 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.


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. 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 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.

Cutting back on the intensity and volume of training is critical to healing ITBS. Stopping for a bit (one to two weeks) while getting treatment may be necessary. Do not train through the pain! A proper warm-up and cool down are also necessary. 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.

The gluteus medius (one of the deep buttocks muscles) is usually very weak in patients that have this syndrome. The gluteus medius is one of the external rotators of the hip and the muscle that is most active when attempting to stabilize the pelvis on one leg. When your hip is flexed to 90 degrees the gluteus medius helps externally rotate your femur. With a weakened gluteus medius the femur stays internally rotated. This causes the fat pad at the lateral aspect of the knee to be exposed to the increased compressive forces from the ITB.

A good exercise to strengthen your gluteus medius is a one leg step down. You will need a step to perform this exercise. Start with your right leg on the edge of the step and the left leg off of it. Now begin to lower yourself onto your left foot (make sure to land on your heel and not the toes). This is accomplished by sitting back and bending your right knee until the left heel touches the ground. Once you have touched the ground push back up. Do not let your right knee collapsing inward. Make sure to keep your knee over your foot.

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. 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!

Quick-Reference Summary for Athletes and Patients:

General Causes

* Leg length differences

* Excessive pronation

* Excessive shoe breakdown (particularly in the outside of the heel) and poor shoe fit

* Training intensity errors such as increasing mileage or intensity too fast

* Muscle imbalances (quads versus hamstrings or hip abductor weakness, specifically the gluteus medius)

* Running gait factors such as bow-leggedness or knock knees

How can bicycling cause ITBS?

* Poor cleat position causes ITBS when cleats are excessively rotated inward

* 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

* Saddle positioning: if it's too far back, it can cause a tightening of the ITB

* High gearing ratios and excessive hill work overstrain the ITB

How can running cause ITBS?

* Running on slanted surfaces always facing the same way. The leg on the slanted edge has to travel a greater distance each time it hits the ground; it's best to vary the route or direction you run so the same leg is not always stressed, or avoid slanted surfaces all together.

* Running on a track always facing the same direction. For example, running counterclockwise forces the ITB in the left thigh to control a greater deceleration of adduction in the left hip. Vary the direction so both legs get a turn controlling deceleration.

* Too much downhill running increases friction on the ITB and fatigues the quadriceps, which help to stabilize the knee.

Dr. Paul Glodzik is a graduate of the National University of Health Sciences and a certified Active Release Technique provider. He is also certified as a strength and conditioning specialist and has worked as a sports performance coach with the Bethesda-Chevy Chase High School Football team, Ashburn Extreme Junior Hockey teams, and Virginia Wild Junior Hockey teams.
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Publication:Running & FitNews
Geographic Code:1USA
Date:Jan 1, 2009
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