Ever been 3km into your run, or 10km into your bike ride and start to feel a pain on the outside of your knee like you’ve been stabbed with a hot knife!? It could be iliotibial band (ITB) syndrome (also known as ITB friction or ITB compression syndrome). If you are a regular runner or cyclist you may be well aware of the love/hate relationship we have with our ITB.
But what is it?
The ITB is a band of thick connective fascia which runs from the iliac crest on your hip, via muscular attachments from the TFL (a hip flexor), and gluteus maximus (powerful hip extensor). The ITB runs down the outside aspect of your thigh, runs over the outside aspect of your knee and inserts onto the front of your tibia (your shin bone). Because of its long length, strong tensile properties and attachments across two big joints (hip and knee), the ITB is a powerful force transmitter and attenuator during the running gait cycle.
What is ITB syndrome?
When your knee is straight, the ITB sits towards the front of the lateral femoral epicondyle (the bony part on the outside of your knee, just above the joint line). As your knee bends, the ITB starts to move backwards towards the back of the lateral femoral epicondyle, at about 30 degrees of flexion there is a peak compression of the ITB over the lateral femoral epicondyle.
Activities with repetitive flexion and extension of the knee (such as running and cycling) can cause the iliotibial band to rub repeatedly along this bony protuberance producing irritation and what is thought to be an inflammatory reaction of the ITB and/or the ITB bursa. There is a bit of debate in the scientific world as to whether it is a true “friction” that causes the pain and inflammation of the ITB bursa, or an actual “compression” and subsequent inflammation of fatty tissue between the ITB and bone of the knee; nonetheless the pain is real so let’s talk about treatment whilst the academics fight out their battle of the PhD’s!
Let’s face it, you’ve probably run or cycled for a long time without this burning pain on the outside of your knee…so why now??
Excess compression/friction of the ITB can be caused by many mechanical factors as well in changes in activity load, however we will try to summarise the basic mechanics of ITB syndrome into three main points:
1: Weak hip muscles: Weak hip abductors (stabilisers) are associated with hip internal rotation, knee adduction and tibial internal rotation (basically the knee rolling towards the inside of your body). These mechanics are associated with excess compression of the ITB at the knee.
2: Tight hip flexors: As previously mentioned, part of the ITB arises from the TFL muscle which is a hip flexor and internal rotator. It is not uncommon for runners and cyclists to develop tight hip flexors over time. These shortened muscles cause extra tension down the chain via the ITB (imagine tugging one end of a seatbelt), as well as hip internal rotation thus causing extra compression of the ITB at the knee.
3: Pronation of the midfoot (flat feet): Having flat feet, or flat arches causes the tibia (shin bone) to rotate inwards through the stance phase of gait. This inward rotation of your shin is one of the main causes of excess compression of the ITB at the knee.
So how the hell do we manage this?
Management can be very individual as the specific cause can vary person to person. However, acutely we want to settle symptoms with a relative reduction in training load, as well as icing and anti-inflammatories (see your GP if considering). Your physio will conduct a full biomechanical assessment to determine where the issue may be arising from in you. A program will be prescribed according to such findings, but a pretty safe place to start is:
- Release your hip flexors, quads and glutes (deep tissue massage, foam roll, trigger ball etc.)
- Hip flexor stretches
- Isolated hip abductor activation and strength exercises, progressing into loaded single leg strength and control exercises
- Trunk strength and control work such as prone holds and side bridges
*Fun fact* The old technique of “rolling out your ITB” is actually being moved away from in the physio world. As your ITB is actually a passive band controlled by the muscles above it (imagine the muscles at your hip are somebody tugging a seatbelt), it is far more effective to release the hip muscles that are producing the tension. If you are hell-bent on rolling your ITB (and a glutton for self-inflicted pain), then go ahead by all means it won’t do any harm, just don’t roll over the sore part of your knee as it will definitely aggravate your symptoms!
#physiocronulla #running #loveyourlife