Iliotibial Band Syndrome (ITBS)
Iliotibial Tibial Band Syndrome (ITBS) is a common injury that affects triathletes, runners and cyclists. Using conventional treatments, this condition never completely resolves since these treatments typically do not address all of the key structures involved in the injury.
ITBS presents as:
- A sharp or burning pain on the lateral aspect of the knee.
- Pain radiating up the side of the hip or thigh.
ITBS is an overuse injury caused by the repetitive action of the iliotibial band as it moves across the lateral femoral epicondyle.
The primary functions of the Iliotibial Band are to:
- Provide static stability to the lateral (outer) aspect of the knee.
- Control adduction (inward motion) and deceleration of the thigh.
- During a run, the ITB performs this function about 90 times per minute, or 22,000 times during a four-hour marathon.
ITBS syndrome in runners usually starts with excessive internal rotation of the femur. In the triathlete, this can result from cycling, followed immediately by running. To effectively resolve this condition, both the internal and external hip rotators must be corrected.
The iliotibial band (ITB) is a wide, flat, ligamentous structure that originates at the iliac crest and inserts on the lateral aspect of the tibia, just below the knee. The iliotibial band serves as a ligamentous connection between the femur (lateral femoral epicondyle) and the lateral tibia (Gerdy’s Tubercle).
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.
- When the ITB is shortened or stressed, the repetitive motion of the knee causes friction and inflammation of the band.
- When the knee is flexed at an angle greater than 30 degrees, the iliotibial band moves back behind the lateral femoral epicondyle.
- During knee extension, the ITB shifts forward in front of the lateral femoral epicondyle.
With ITBS, the bursa often become inflamed, causing a clicking sensation as the knee flexes and extends.
This diagram shows the Correct Cleat Position.
The cleat is aligned with the bicycle frame.
This diagram shows an Incorrect Cleat Position.
The cleat points away from the bicycle frame.
Common causes of ITBS in cyclists include:
- Poor cleat position. ITBS results when cleats are excessively rotated internally. The feet should feel straight when clipped into the pedals, with no torsional or twisting stress occurring when you are pedaling.
- Incorrect saddle height. The saddle height should be set so that your legs are almost fully extended at the bottom of each pedal stroke. Keep the following points in mind when adjusting saddle height: Your hips should not rock back and forth when pedaling. If they do, lower your saddle. If the saddle is too high, you will have to stretch your legs too far to reach the bottom of the pedal stroke.
- Poor saddle positions. Bike saddles that are positioned too far back cause a tightening of the ITB by forcing the cyclist to reach for the pedal with each stroke.
- High gearing ratios. This may cause excessive generation of force by the ITB.
- Excessive hill work. It is important to gradually increase hill work to avoid stressing the ITB.
Impingement of the ITB against the lateral epicondyle of the femur occurs just after foot strike in the gait cycle.
Runners typically do not experience pain from the ITBS until the first one or two miles of a workout have been completed.
Common causes of ITBS in runners include:
- Running on slanted surfaces such as a circular track
- Excessive downhill runs
- Increasing mileage or pace too quickly
- Weak knee flexors and extensors
- Weak hip abductor causing excessive internal rotation of the knee
- Weak gluteus medius causing internal rotation of the thigh
- Pronation causing internal rotation of the knee
- Bow legs (Genu Varum)
- Leg length discrepancy
Always Consider the Kinetic Chain
The entire kinetic chain (above and below the injury) must perform properly in order to ensure effectiveness of the treatment, and to ensure optimum performance at the sport. Patterns of dysfunction will develop if any segment of the kinetic chain is not functioning properly.
Treatment can vary greatly since ITBS can be caused by dysfunctions in structures along any part of the kinetic chain. Different athletes may have different types of restrictions and soft-tissue injuries, but still show exactly the same pain symptoms.
This is why generic treatment methodologies often do not work when treating ITBS.
Learn more about the knee’s kinetic chain on Dr. Abelson’s blog.
ITBS can be caused by damage to many different soft tissues, but the underlying injury process is very similar for all the soft tissues.
Changes in biomechanics causes increased stress, internal pressure, and increased friction that leads to inflammation, and eventually, the formation of adhesions (scar tissue) within the ITB or along its kinetic chain.
Scar tissue is like glue; it restricts the translation or movement of adjacent tissues, causing friction, and leads to inflammation. The following diagram illustrates this classic Cumulative Injury Cycle.
Chronic irritation leads to small tears within the ITB. This produces an inflammatory reaction. Once the inflammatory condition has started, even simple tasks such as walking can put considerable internal pressure on the ITB.
This constant internal pressure limits circulation to the tissue, resulting in decreased delivery of oxygen to soft tissues. Decreased oxygen causes several biochemical changes that result in the formation of yet more adhesions within the ITB.
This in turn creates more restrictions, inflammation, and swelling. The body responds to inflammation by laying down additional scar tissue (cross fibers across the tissue) in an attempt to stabilize the affected area. This scar tissue:
- Restricts motion
- Reduces circulation
- Inhibits nerve function
- Causes ongoing friction and pressure
- Results in the production of yet more cross fibers and adhesions across inflamed soft tissues
It is extremely important to be as specific as possible when identifying the soft tissue structures involved in any condition. Different athletes may present with identical pain patterns at the ITB, yet they may have completely different structures that are impairing motion or causing the injury.
Before treatment takes place, an extremely accurate examination and diagnosis must be performed. It is important to look past the initial point of pain and identify all the other structures that are involved in the kinetic chain.
Because of the inflammatory nature of this injury, it is highly recommended that the athlete use ice massage, for 3-5 minutes, over the affected area until it is numb. The more acute the condition the more essential ice massage becomes.
Usually, for conventional treatment for ITBS, a reduction or stop in training is necessary.
See our page on Cold Therapy and Icing.
This pause in training is often unnecessary with Active Release Technique (ART). With ART, the athlete is often able to resume training within a very short period. In fact, for most moderate cases of ITBS, the athlete is able to immediately increase the level of training after an ART treatment, without discomfort.
This is one of the great advantages of Active Release Techniques for improving performance. With ART, you can prevent injuries from affecting your training schedule. The equation is simple, decreased injuries means more time for training and for increasing performance.
To truly resolve ITBS, every structure that crosses the lateral side of the knee must be evaluated and treated. In addition to the ITB, the practitioner must also evaluate and treat the muscles, ligaments, meniscus, and capsule.
Once this is done, the hip itself must be corrected to remove the root cause of the problem.
Unfortunately, it is common for this condition to never fully resolve, since practitioners rarely evaluate and treat ALL of these structures.
Effective treatment of the ITBS, or of any soft-tissue injury, requires an alteration in tissue structure to break up the restrictive cross-fibre adhesions and restore normal function to the affected soft-tissue areas. When executed properly, this process substantially decreases healing time, treats the root cause of the injury, and improves athletic performance.
Watch our ITBS video in YouTube to better understand how we work with ITBS!
The first step in treating this condition is to perform a biomechanical analysis of the athlete to determine where the restrictions are located along the entire kinetic chain.
Treatments need to be specific and based upon the individual needs of each athlete. It is not a cookbook approach to treating a non-specific diagnosis.
The practitioner needs to find the specific tissues that are restricted and physically work them back to their normal texture, tension, and length by using various hand positions and soft-tissue manipulation methods.
With the right specific treatment, we often see immediate improvement after we identify and work with the damaged structures.
Strengthening exercises are only effective if they are executed after the adhesions within the soft tissue have been released. Attempts to strengthen muscles bound by adhesions often cause the structure to become more restricted, which in turn causes additional tension within the soft-tissue.
In addition to the strengthening component, stretching, and balance work continue to be key components in correcting the problem so it does not return.