So what is the ITB, and its role in the body?
The ITB is a lateral hip stabilizer that blends with muscles called the Tensor Fascia Latae (TFL) and the Gluteus Maximus. The ITB along with the TFL aids in hip abduction and internal rotation, and knee extension.
It attaches to the pelvis, and then runs down the side of your thigh, past the outside of the knee (lateral epicondyle of the knee) connecting to the outside edge of the tibia and head of fibula (shinbones just below the knee joint).
Research to date is a bit inconsistent, in the sense that some studies suggest that there is a bursa in the knee, while others don’t. The bursa is a fluid filled sac, that acts as a cushion for soft tissues from friction, such as where the muscles tendons glide over one another.
What is ITB Syndrome?
ITB syndrome occurs when the ITB repeatedly flicks or rubs on the lateral femoral epicondyle of the femur (outside of the knee) causing a “hot spot” of pain or aching, inflammation and/or irritation.
This “hot spot” tends to occur in what’s called the “impingement zone” which occurs just after heel strike, when the knee is in approximately 20-30 degrees of knee bend (flexion). One study also reported that pain can also be felt during weight bearing (such as standing, squatting), where the knee is held in the 20-30 degree of knee bends in stance. Other symptoms reported, include radiating pain towards the hip and towards the lower leg, as well as tenderness, grating, crackling, and popping sounds and/or sensations.
There are a number of identifying factors that predispose individuals to developing ITB syndrome.
According to research there are a number of factors that may contribute to ITB syndrome, these can be from a biomechanical nature, muscle imbalances, poor technique as well as the type of training you do.
1. Poor mobility
Runners that have reduced hip mobility, particularly extension (ability to take the leg backwards), generally externally rotate, or turn the leg/foot outwards as they then go to heel strike the ground, resulting in an enormous load and strain being placed through the outside of the knee.
Any jumping or landing with the foot turned out, commonly seen in a power clean receiving position or when running, also results in excess strain/load. The ITB connective tissue attached to the knee during this motion is pulling the knee into a outwards motion, and can result in insertional issues where ITB attaches at the knee. If you can imagine the repetitive nature that is 400m, the amount of steps you are taking for this event can be approximately 330 steps per minute per leg, so when longer distances come into play, the steps per minute will significantly increase, it is no wonder that the ITB becomes a hot spot and results in soft tissue irritation.
3. Downhill running
ITB syndrome can be exacerbated by downhill running. Compared to level ground running, downhill running is associated with more of an extended/ straightened knee position, with knee bend on foot strike reduced, increasing friction as the knee spends more time in the ‘impingement zone’.
If your knee cap tracks inward, also known as Patella mal-tracking, it can be the result of a very tight ITB and TFL tissues that is pulling on the outside of the knee, placing excessive strain. Patella mal-tracking issues can also lead to Patella dislocations, this will require specific knee strengthening exercises, and is also an option for extreme cases such as a lateral release surgical procedure if this is the case.
5. Muscle imbalances
Muscle imbalances can play a big role in ITB syndrome. Research has shown that those that suffer had weak hip muscles, particularly the abductor and external rotator muscles, which essentially control and move your leg out to the side and turn the leg outwards. Some other studies show that individuals can also have knee muscle weakness in both straightening and bending the knee.
Weakness and fatigue can result in increased compressive forces around the outside of the knee and therefore lead to ITB syndrome. This can lead to not only hip muscle imbalances, but altered biomechanics as well.
Tightness may be present and can occur secondary to shortening of the TFL and/or gluteus maximus muscles, or excessive development of the knee muscles, particularly the vastus lateralis, placing increased tension and load on the ITB.
Other risk factors of ITB syndrome can include other abnormal running and cycling movement patterns that may increase risk of developing ITB syndrome, poor footwear choices, and training errors including inappropriate increases in distance, volume and/or pace.
Stretching and icing together are grouped together as both have conflicting research, some say that they have some great benefits, while others not so much, so I will let you decide!
Stretching is a hugely proposed treatment strategy for ITB syndrome in many studies. However stretching the ITB may actually be wrong, as the ITB itself is not designed to stretch. According to Kelly Starrett, a Physical Therapist in the US, when the ITB in a cadaver was stretched, it only has the ability to stretch 3-4% of its normal length, and to even stretch it requires a significant force to do so. Any excessive stretching increases the likelihood of tears.
Therefore, by trying to place the ITB on stretch, you may be putting yourself at risk of tears, and should be taken into consideration. Other areas such as the TFL, gluteus maximus may prove more beneficial because of its close relationship to the ITB.
Some studies recommend icing, especially after competition, and I know that some people I have spoken to do use ice. However some studies state that ice can actually hinder the healing process.
When foam rolling, many people roll super quick and although soreness may play a big factor in that, it is the wrong way to tackle it!
You should be able to put large amounts of pressure on areas of the ITB without it hurting (and it might take some time to get to this point if you don't do it regularly enough), it is best by working up (towards the hip) and down the leg (towards the knee, and below) really slowly and targeting common trigger point areas such as the gluteals, TFL, quadriceps (best to foam roll at a 45 degree angle), and outside of the lower leg (peroneals), as the ITB fascia attaches past the knee.
If you do happen to suffer any of these nasty trigger points, it is best to hold the position for a minute or so. You can also add a tacking movement, in which you hold down on the trigger point area and then adding movement on top, by doing this you are effectively stretching the tacked down area and loosening the muscle. An example of this would be outside of the lower leg where you would point your foot down and up; or the quadriceps where you can bend and straighten the leg.
Other great tools can be used, such as a rumble roller, and a lacrosse ball if you're hardcore. A peanut shaped tool such as the Yoga-tune up balls can also be used as a stacking exercise to buy extra slack at the insertional ITB area, while incorporating the lateral quad muscles.
Massage of the myofascial trigger points has been associated with decreased stiffness and lengthening of the TFL/ITB complex.
If weakness is identified, then strengthening those weak areas is key. As studies suggest, targeting the muscles involved with hip abduction and hip control is ideal as this will help reduce symptoms and prevent re-occurrences of ITB syndrome.
Many studies have many approaches to strengthening, one suggests starting with open-chain type exercises (such as standing side-leg lifts) before progressing to a more closed-chain exercise, single-leg step downs and pelvic control exercises. Another had shown benefits when eccentric loading intervention was used.
Strength exercises should be performed on both legs, not just the painful one, with some studies suggesting to start with 5 to 8 repetitions with gradual progression of 2 to 3 sets of 15 repetitions. Some great exercises incorporated into these studies include hip hikes, clams, step downs, side-to-side crab walks (pictured with band resistance), and hip control exercise on the wall.
Co-contraction of the internal and external rotators is necessary to provide stability to the femoral head in the acetabulum during loading.
When someone has irritation to the lateral knee, it may result in poor healing, poor hydration and poor blood perfusion. A compression band can be used here to bring blood flow back and re-hydrate the insertion point, it may also free up the area and facilitate healing. However results are based on clinical evidence, not research to date.
When using the band, apply the compression with the band on 1/2 stretch and overlapping by 1/2 on the thigh above the knee. Once applied you will then hold onto something so you are able to perform some deep squats, after 10-15 repetitions take the band off. To see if it has made a difference, you can do a squat test before and after.
Rock tape is a great application to use for ITB syndrome. The application itself can be used in a variety of ways to achieve different benefits. When applied with little or no stretch on the tape, but lots of stretch on the tissue, it causes the skin to form wrinkles. This creates a biomechanical lifting mechanism that decompresses the tissue just under the skin. It is believed that this decompression and having the tape on the skin creates 3 main effects; fluid, mechanical and neurological.
When applied with more stretch, it can be used to support areas where tissue has been strained, torn, weakened or stretched. By adding more elastic recoil to the taped area, functional stability and tissue ‘snapback’ are enhanced. Head to Rocktape Australia’s youtube page for a great video on how to apply the tape for the ITB among many other cool videos.
Getting back into running again after suffering from ITB syndrome can be varied, and it depends on how severe it was and how long you have had it. Some studies suggest that most fully recover by 6 week, however when it comes down to returning to running, they suggest that you can return once you can perform open-chain and closed-chain strengthening exercises with proper form and without pain, some of the exercises are mentioned above in the strengthening section. From weeks 3 to 4, you are able to then gradually increase you're running distance and frequency until your back to your normal training routine!
Interestingly, some studies have shown that faster-paced running is less likely to aggravate the ITB because at foot strike, the knee is bent beyond 30 degrees and out of the ‘zone of impingement’.
Conservative treatment such as the strategies mentioned above have been show to be very successful, in fact, studies report a 94% success rate, so why wouldn't you give conservative strategies such as those mentioned above, a try first! If you want something a little more tailored to your injury, it would be best advised to arrange an appointment to see your local Physiotherapist.
You can have other strategies that require input from a health professional such as a Physio or Specialist, however they might be a little more intense or invasive, they can include cortisone injections, dry needling, anti-inflammatory medications and surgery. It would be recommended to seek consultation from someone like a Physio before considering these types of options.
Yours in health,
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