RUNNING AND ILLIOTIBIAL BAND SYNDROME (ITBS)

Ellen Pavlovic, DPT Doctor of Physiotherapy

Sports Physiotherapist, Dubai

 

 

 

 

One of the most common injuries among runners, especially distance runners, is iliotibial band syndrome (ITBS), which is typically an overuse injury. The main role of ITB is to provide lateral, or outside, the stability of the hip and knee. Because it is cross 2-joints, there are many different factors that can cause this and hence many different treatment and prevention options.

As always, if you suspect an injury, proper care and appropriate medical consultations by your local sports medicine doctor and/or physiotherapist will keep you running strong!

ITB 101:

 

  • The ITB inserts along the length of the thigh bone, the femur, with the tensor fascia lata muscle inserting into it as well as a large part of the gluteus maximus muscle by the hip. It then travels down to the knee where it crosses the lateral femoral epicondyle (the outside bony prominence of the femur) and inserts onto the patella (knee cap) and a bony prominence called Gerdy’s tubercle on the tibia (shin bone).

 

 

 

 

 

 

 

 

 

  • ITB is actually not a discrete band, but a ‘thickening’ of the circumferential fascia that envelops the whole thigh, similar to a stocking.

 

 

 

 

 

 

 

 

 

  • The primary role of the ITB is to provide lateral (outside) stability of the hip and knee complex and resist hip abduction (hip going outwards) and knee internal rotation (the leg, tibia, going inwards).
  • The ITB is referred to as “soft steel” among medical professionals as it is quite tough and fibrous, and hence can explain why it is so difficult to mobilize (helloooo foam roll!)!

 Causes of injury:

 

  • Recent evidence does not support the common theory that ITB problems develop from “friction” of a bursa underneath the ITB as it crosses the lateral femoral condyle (bony prominence of the femur, or thigh bone). Instead, it is a vascularized layer of fat and connective tissue underneath that is the likely source of pain that is being compressed.
  • When there is altered tension of the hip and thigh muscles from muscular imbalances, particularly weakness, the band has to work harder and becomes more and more taut. Hence it loads compressive forces at the bony prominence where the ITB crosses that lead to pain.
  • The most common cause of ITB injury is faulty biomechanics from hip weakness! This is because there is more tendency of the hip to go into adduction (inwards) when the gluteals (Maximus, medius, and minimus) are weak and this leads to abnormally increased pull on the ITB which can then lead to the internal rotation of the tibia (lower leg going inwards), both causes and contributions of creating too much compressive forces to the ITB. Particularly, weakness of the gluteal muscles in ITBS causes abnormal biomechanical changes that affect the entire biomechanics of the body (hip to foot, foot to hip).
  • Abnormal foot mechanics is a big component of ITB as this can cause the tibia (lower leg bone) to rotate and thus creating a pull and compression on the ITB.
  • Old worn-out shoes (especially at the heel), running on a slope for too long, training errors such as increasing mileage and intensity too quickly, muscular imbalances, pelvic alignment abnormalities, too many track workouts in the same direction (seriously!), being bow-legged or knock-kneed, too much downhill running, are a few more common causes.

 

In tribute to the Dubai Creek Striders ½ marathon, here is a list of:

TOP 13.1 PREVENTION TIPS:

 

  1. 2 words: Foam Roll, Tennis Ball, Golf Ball! This should be a runner’s BFF. It provides a big myofascial and trigger release for this taut structure. Particular attention should be to ALL the thigh muscles as again, the “band” envelopes the whole thigh, so you need to foam roll the hamstrings, quadriceps, gluteals, ITB, tensor fascia lata (TFL – the muscle above the ITB that completely inserts in it), and even calves. Particularly, when the TFL or gluteal muscles (gluteus maximus) are too tight or contracted, it pulls on the ITB and causes it to increase its’ toughness, so foam rolling these structures is important. Hence, although torturous, when foam rolling, you need to go all the way to the top of the hip above hip bone (to get the TFL) and all the way down to the top of the knee to get the entire length of the TFL and ITB! It’s also useful to turn your body inwards and outwards when you are rolling to release more of the fascial tightness from the neighboring muscles.
  2. Strengthen the hip abductors, particularly the gluteus maximus and gluteus medius muscle as the majority of these fibers insert into the ITBS.  It may sound familiar, but these muscles particularly have an influence on ITBS and are often found weak. Again, when this is weak it causes an inward pull of the hip (adduction force) and thus more stress on the ITB.
  3. Do a proper warm-up and cool-down before and after running. Especially before running, do a dynamic warm-up such as skipping, walking, or jogging with high knees, butt kicks, straight leg scissor kicks.
  4. Give your body some rest if you suspect injury! Inadequate rest and recovery associated with greater training volume can cause access fatigue and thus strain on your muscles and make you more susceptible to injury.
  5. Ice massage over the particular area (especially with ITB if it is at the knee), it can help calm down the pain. You can get a paper cup filled with water and freeze it, then rip off the bottom and do the ice massage on that area OR get a plastic cup, fill it with water and a tongue depressor, freeze it, then wiggle it out and ice massage the sore area.
  6. Stretching before and after each run, as well all should know is important. With ITB, it is especially important to stretch not only the ITB but also the gluteal muscles. All advised to hold for 20-30 seconds and perform 2-3x/each.
  7. During recovery, try to avoid high impact flexion-extension activities of the knee, including running, cycling, stair climbing. Modified exercises such as elliptical/cross-trainer machines, swimming, and walking are suitable. Walking/running in the water is an excellent exercise while you are recovering from injury, it is advised for most all lower extremity injuries because it maintains your cardiovascular fitness while avoiding the impact of running and keeps the legs strong.
  8. Proper shoe wear is extremely important for those individuals that suffer from ITB. Faulty shoes can alter your mechanics and place more strain on the ITB because of its’ attachment below the knee. Make sure your shoes are not too worn out and properly fit for you. If you have doubts, have your feet and shoes evaluated by a qualified healthcare professional.
  9. Because tightness of the gluteal muscles and tensor fascia lata (muscles that almost fully attach to the ITB) are commonly associated with ITBS, it’s common to have tightness and trigger points there. To release this, options are myofascial, trigger, and active releases by a trained professional, and also dry needling.
  10. When exercising, stretching, or cross-training injured, DO NOT provoke pain! ALL stretches and exercises should be PAINFREE! AVOID activities that cause pain and STOP activity when there is a pain!
  11. If you do have pain on the outside of your knee or your hip, you should not always assume that it is your ITB. Your sports medicine doctor and/or physiotherapist should examine you. If necessary, it may be advisable to have a diagnostic ultrasound or MRI to determine the exact location and extent of the injury.
  12. Off-season or on-season, it is always beneficial to cross-train to maintain muscular endurance. Of particular importance is strengthening core muscles (pilates anyone?)
  13. Always remember with high impact nature of running, biomechanical changes from injury or fatigue can affect other structures.

13.1 DCS Summary of Prevention Tips:

 

Do seek professional help if you suspect injury

Care and listen to your body

Successful and safe running requires knowledge of the body

Disclaimer: ALWAYS CONSULT A TRAINED PROFESSIONAL!

 

The information in this resource is general in nature and is only intended to provide a summary of the subject matter covered. It is not a substitute for medical advice and you should always consult a trained professional practicing in the area of sports medicine in relation to any injury. You use or rely on information in this resource at your own risk and no party involved in the production of this resource accepts any responsibility for the information contained within it or your use of that information.

References:

 

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Fairclough, J. et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of Anatomy 2006;208(3):309-316

Fairclough, J. et al. Is iliotibial band syndrome really a friction syndrome? J Sci Med Sport. 2007 Apr;10(2):74-6.

Ferber R, Davis I, Hamil J, Pollard CD. Prospective biomechanical investigation of iliotibial band syndrome in competitive female runners [abstract]. Med Sci Sports Exerc. 2003;35:S91.

Ferber R, Davis IM, Williams DS, 3rd. Gender differences in lower extremity mechanics during running. Clin Biomech (Bristol, Avon). 2003;18:350-357.

Ferber R, Noehren B, Hamill J, et al. Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics. J Ortho Sports Physical Therapy 2010; 40 (2): 51-58.

Fredericson, M. et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sports Med 2000;10:169–175.

Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sports Med. 2000;10:169-175.

Hamill J, van Emmerik RE, Heiderscheit BC, Li L. A dynamical systems approach to lower extremity running injuries. Clin Biomech (Bristol, Avon). 1999;14:297-308.

Messier SP, Edwards DG, Martin DF, et al. Etiology of iliotibial band friction syndrome in distance runners. Med Sci Sports Exerc. 1995;27:951-960.

Miller RH, Lowry JL, Meardon SA, Gillette JC. Lower extremity mechanics of iliotibial band syndrome during an exhaustive run. Gait Posture. 2007;26:407-413. http://dx.doi.org/10.1016/j.gaitpost.2006.10.007

Niemuth PE, Johnson RJ, Myers MJ, Thieman TJ. Hip muscle weakness and overuse injuries in recreational runners. Clin J Sports Med. 2005;15:14-21.

Noehren B, Davis I, Hamill J. ASB clinical biomechanics award winner 2006 prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomech (Bristol, Avon). 2007;22:951-956. http://dx.doi.org/10.1016/j.clinbiomech.2007.07.001

Orchard JW, Fricker PA, Abud AT, Mason BR. Bio¬mechanics of iliotibial band friction syndrome in runners. Am J Sports Med. 1996;24:375-379.

Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36:95-101. Terry GC, Hughston JC, Norwood LA. The anatomy of the iliopatellar band and iliotibial tract. Am J Sports Med. 1986;14:39-45.

Williams DS, 3rd, McClay IS, Hamill J. Arch structure and injury patterns in runners. Clin Biomech (Bristol, Avon). 2001;16:341-347.

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