Iliotibial band pain syndrome (ITBPS) can leave the runner crippled in pain, and often appears like clockwork at a given point during a run, with the runner unable to run “through” the pain. ITBPS comprises between 1.9-12% of all running injuries (Lopes 2012). However, this injury is not unique to runners: it can be seen in field athletes, basketball players, rowers & has been reported to occur in up to 24% of road cyclists. (Holmes 1993)
What is the ITB?
The iliotibial band is a tendon-like structure that runs all the way down the outside of the thigh from the hip bone to the knee where it attaches to the tibia, femur, fibula & patella. It provides attachment to the gluteus maximus & TFL muscles at the hip, & could be referred to as the “deltoid muscle of the hip”.
What is the ITB’s function?
Due to the ITB being largely fascial tissue, it’s role is to adapt to and transfer force when walking, running, jumping & hopping, & forms an important role in stabilizing the hip. The ITB along with the TFL & glut max resist hip adduction & internal rotation (hip coming inwards) and also resist the tibia (shin bone) from moving forwards and spinning internally during loading.
Interesting facts about the ITB
Humans are the only species that have an ITB
We don’t have an ITB at birth, it only develops once we start walking
The ITB is STRONG - it can withstand 90kg of stretching force before stretching (Seeber 2020)
What are the symptoms of ITB pain?
The pain with ITBPS is felt around the outside of the knee. It will often appear around the same time during a run i.e. 6km, & sufferers will rarely be able to run through the pain. Downhill running & going downstairs will tend to aggravate the pain. When especially irritated, walking can be painful.
What causes ITB pain?
Initially termed “ITB friction syndrome”, we now know from numerous studies that it’s not friction but more compression of the ITB that contributes to the pain. (Geisler 2021) The ITB is placed under the greatest compression when the knee is bent between 20-30degrees during the stance phase of gait.
From the work of Hamill, we learn that strain RATE is more important than the amount of strain in the formation of ITBPS. If there is a decreased ability of the body to absorb shock during the 20-30degrees of knee flexion during the stance phase of running, then the ITB experiences a rapid increase in strain, & compression of the ITB can result. A potential reason why ITBPS appears at a certain point in a run may be due to fatigue of the muscles of the hip & leg, which then increase ITB compression.
Managing ITB pain
Firstly get a DIAGNOSIS from a health practitioner that deals with runners! It’s important to know exactly what has been injured. Once you have a diagnosis, then get a PLAN moving forward! A thorough assessment will ensure that treatment and rehabilitation can address any issues identified, and reduce the chances of you suffering another injury, and get you back out there as soon as possible.
It’s vital to see your health practitioner to firstly assess and diagnose your problem and secondly to create an INDIVIDUALIZED rehabilitation program.
Here is an example of some of the things that we will get patients to do optimize recovering from ITB pain:
What is our unique approach to ITB pain?
At Health & High Performance we pride ourselves on a thorough examination to ensure an accurate diagnosis to then lead to targeted treatment, allowing you to get back to sport as soon as possible.
Firstly it is important to have a thorough discussion about your problem and some of the factors that may have contributed to it. This can include training errors (doing too much too soon & inconsistent training) or insufficient recovery (ie. high stress and poor sleep).
Using our state of the art technology, the AxIT system, we are able to measure hip & leg strength to assist in predicting & guiding return to play. Read more about the AxIT system here.
Consideration of the role that other areas played in your injury: for instance, foot strength, low back pain, hip problems, or even previous ankle sprains may contribute to your injury. Your examination with us will cover all these areas, and your management plan will include solutions to these additional issues.
Rehabilitation & return to sport
“Every injury is unique, treatment should be too”
Immediately commencing rehabilitation: from Day 1 there will be exercises you can perform to hasten your recovery. These exercises are prescribed according to criteria (what you can/can’t do) not just based on time. In a 2017 study by Bayer et al, they compared commencing rehab at 2 days versus 9 days, and found that those starting rehab 1 week earlier, returned to their sport a staggering 3 weeks earlier! Click here to read more
Below is a guide to some exercises that can be used for the rehabilitation of ITB pain. Your sports chiropractor or physiotherapist should individualize these exercises after a thorough assessment.
A loss of hip abduction & external rotation strength has been found in those with ITBPS, and research has also shown those who restore strength in these muscles also improve their pain. (Fredericson 2000, Geisler 2020)
It is also important to assess the whole kinetic chain in those with ITBPS. In our experience, it is not uncommon to see a loss of strength in the calf & quads accompanying weakness in the hip muscles in those with ITBPS. Poor ability of these muscles to eccentrically control deceleration of the hip & knee during the stance phase can cause an increase in hip adduction & internal rotation, & places a higher strain rate on the ITB, & resultant compression.
A thorough strength assessment will determine if you have the required strength in these areas, which will then allow for a tailored strengthening program to be implemented to address any deficits.
Shallow squats and lunges can be progressed to full depth, rear leg elevated split squats, single-leg step downs, lateral lunges. Then progressing to plyometrics with jumping, hopping & lateral skater jumps.
Those with a sudden change in running volume are more prone to developing ITBPS (Nielsen 2013). In addition, hill running, especially downhill running is often aggravating for those with ITB.
For those too sore to run, walking with shorter steps on flat ground, or swimming can be an option if a bike is not tolerated.
Some tips on returning to running for those with ITBPS (read our blog here on this topic):
Avoid hill running & surfaces with a high camber. If running hills, run the uphill & walk downhill.
Running on a treadmill with a 3-5% incline can be used if running on a flat surface is too sore
Seeing as a sudden change in running volume can trigger ITBPS, increase training volume slowly, but speed may be introduced earlier on.
Similar to patellofemoral pain (Runner’s knee), runners exhibiting increased hip abduction and internal rotation when running have been related to ITBPS. (Aderem 2015. Miller 2008)
Things to look for & potentially correct in those with ITBPS:
Increased pelvic drop
Increased hip adduction & internal rotation
Narrow step width
What about stretching the ITB?
It has long been considered that a “tight” ITB is a contributing factor to developing ITBPS. Interestingly a test commonly used to assess ITB “tightness”, the Ober’s test, was examined in a recent study by Willet. The authors found that dissecting the ITB, did NOT improve hip adduction motion & that it was the gluteus medius, gluteus minimus & hip joint capsule that restricted this motion. (Willet 2016)
In addition, even if the ITB is deemed “tight” no amount of stretching is able to create an appreciable change in its length. (Falvey 2010).
Key takeaway here: Don’t bother with stretching the ITB
The same can also be applied to foam rolling and massage directly to the ITB!
Need further help?
Please don't hesitate to contact us for a thorough assessment of your ITB issues & to formulate a plan to get you back to health & high performance!
Health & High Performance “Realize your goals”
Free E-Book & Video
"5 Keys to Injury Free Running"