What on earth is Iliotibial Band Friction Syndrome?

by G. John Mullen, DPT 2011

IT Band SyndromeWho doesn’t want to be in great shape?  Ask around and you’ll be hard pressed to find an individual that is actively trying to be out of shape.  So what is it that we, as a society, do when we decide to get in shape? We go running.  Running is the most popular and simplest form of exercise. The most popular and simplest form of exercise is running.  Running is great cardiovascular exercise, however many injuries stem from running and often arise from doing too much too early.  One of the most common injuries is iliotibial band friction syndrome (ITBFS).  This injury can linger for long periods of time without quick and proper treatment but if assessed and treated soon, the effects can be mitigated.

Stat Fact: Health club memberships typically increase 12% in the month of January (4).

What is ITBFS?

IT Band Friction SyndromeThe iliotibial band is a fibrous band that runs on the outside of your leg from your hip to your knee.  It is generally firm, but as it is irritated it may become extremely tough and sensitive.  Irritation of the iliotibial band can be due to poor biomechanics, anatomical flaws or muscle weakness.  Many of the biomechanical flaws stem from muscle weakness, but the anatomical flaws are a bit trickier.  The main anatomical flaw is flat feet, which causes your knee to internally rotate with each step, subsequently stretching your IT band.  While stretching is typically good, when done repeatedly it can break down the tissue and inflammation and tightness can occur.  The most common biomechanical flaw is too much hip adduction (bringing your thigh bones close to one another) and internal rotation (rotation of the knee inward) of the thigh bone (femur).  This motion is controlled by the gluteus maximus (the upper fibers to be exact…also the sexiest muscle in the body) and if this muscle is weak it can cause repeated stretching of the muscle leading to problems similar to those seen with anatomical flaws.  These are the main causes of ITBFS, but many other anatomical issues may cause ITBFS (leg length discrepancy, bowed legs, previous injury, improper footwear, etc.).  However, simple muscle strengthening is not the solution, especially if you already have ITBFS.

What should I do if I have ITBFS?

First, go see your physician to get a referral to a physical therapist.  Make sure your physical therapist watches you walking, running, and explains what is going on biomechanicallyIT Band Soft Tissue Mobilization with Foam Roller because it is essential to understand the problem before it can be resolved.  Some modalities (ice, electrical stimulation, etc.) may be used to decrease pain and inflammation, but these things will only solve the problem temporarily. A proper running analysis, combined with a stretching and strengthening program will be most beneficial in the long run (yes, this is a purposefully placed pun).  Every physical therapist will have their own unique treatment style but, as an overview, it should include:
•    Diagnoses and evaluation of the injury
•    If ITBFS is determined, a temporary termination from running will be suggested to allow proper healing
•    The need for shoe lifts, inserts, orthotics, etc. will be assessed
•    Modalities will be used to treat inflammation and pain
•    Soft tissue mobilization to break up the tightness in the ITB (see image above utilizing a foam roller)
•    Stretching will be used to provide proper leg length
•    Strengthening will be combined with stretching and, when proper muscle activation is achieved, return to sport is indicated

Stat Fact: ITBFS has been reported to cause of 12% of all running-related injuries (5).

Prevention of ITBFS


If you do not have ITBFS but reading articles on running forums and Running World have scared you into learning about the pathology, then this is the section for you.  Remember, an ounce of prevention can go a long way.

Proper Warm-up
To stop ITBFS before it begins, a proper warm-up is necessary prior to any workout.  This warm-up should not be a light jog!  A good warm-up involves at least of 5-10 minutes of multi-directional movements of the legs and arms.  Sport specific warm-up and dynamic (moving) stretching for at least 10 minutes must also be utilized to properly warm-up and stretch your muscles (3).  Imagine trying to stretch a rubber band that’s been in the freezer.  Not a good idea, we promise.

Example Warm-up for Jogging:
•    10 minutes of jogging which includes repeated bouts of: high knees, butt kickers, skipping, side-stepping, karaoke, backwards running and high knee hip rotation
•    10 minutes of marching with legs raises in front, leg raises to side, skipping, leg swims (forward and side-to-side), lunges, side lunges, higher speed training

Proper Cool-Down

After each workout a cool-down of at least 10-15 minutes is recommended.  This warm-down should not just be walking, jogging, smoking a cigarette or drinking a coffee (or any combination of those).  A proper cool-down encompasses some jogging at a slightly lower intensity than the main workout, dynamic stretching, isometric stretching and relaxed stretching (1).

Example of Cool-down for Jogging:
•    5 minutes jogging that includes walking lunges and high knees.
•    5 minutes of isometric stretching: standing legs spread stretch to each side, standing calf stretch, seated IT band stretch (see image), IT band foam rolling or tennis ball rolling (these may be painful in the beginning), side lunge stretch (all of these stretches should be performed for at least 30 second holds)
•    5 minutes of relaxed stretching: seated legs spread stretch, forward lunge stretch, semistraddle, side quadriceps stretch, lunging IT band stretch.

Strengthening

As previously mentioned, most biomechanical ITBFS is caused by weak upper gluteus muscles.  However, simple squats won’t fix the problem because running relies on eccentric strength of the hip extensors (hamstrings, glutes).  Eccentric strength refers to muscle lengthening as opposed to concentric strength which refers to muscle shortening.  In a bicep curl, the curling of the dumbbell towards your shoulder is the concentric phase of the exercise and the lowering of the dumbbell towards your side is the eccentric phase of the exercise.  It is essential to meet with a strength and conditioning professional or physical therapist to help design a proper training program to strengthen this muscle properly and apply correct training principles.  Poor training = poor results and nobody likes walking around with a bum leg.

Example Strengthening of the Gluteus Maximus

Overview

The amount of repetitions and sets will vary depending on your primary goal and current level of conditioning.  The ultimate goal is 3 sets of 10 repetitions each.  If the exercise is too easy, add weight to increase difficulty.  Some exercises will be more difficult.  In these instances, you should reduce the number of repetitions to prevent injury and slowly work your way up to three sets of ten.

Beginner:Bridge

Bridging:

Lie on your back with your knees bent and feet shoulder width apart, push through your heels to lift your butt off the ground as high as you can (possibly into hyperextension).  Hold this position for a second and then lower your butt back to the floor.  This is one repetition.

Clams:

ClamLie on your side and bend your knees to 90 degrees and your hips at 60 degree with your legs one on top of the other.  Now lift your top leg open like a clam, hold for a second and then return your knee to the starting position.  Brilliant!  Complete 3 sets of 10-20 repetitions on each side.

Intermediate:

Single Leg Deadlift:

ThiSingle Leg Dead Lifts exercise is similar to the single leg squat.  To begin, stand on one foot and bend your knee slightly (~10 degree).  Now bend at your hip bringing your chest towards the floor and touch the ground next to your foot with the opposite hand.   Hold for a second and return to the standing position.  Repeat 3 sets of 10 repetitions on each side.  To advance, you can add dumbbell weights in each hand.

Band Seated Abduction:

While seated, take a resistance band and wrap it around your thighs.  Once in this position, rotate your hips outwards by opening up your legs (similar to the clam exercise, but seated).  You should feel a burn in the lateral aspect (the outside) of your hip.

Advanced:

Kneeling Glute-Ham Fall:

Kneeling Glut Ham FallBegin in the tall kneeling position (see picture) and have a partner hold onto the back of your heels to stabilize you.  Now lower yourself as slow as possible to the floor maintaining your upper body in a straight line as you lower yourself to the floor from your knees.  This can be advanced by holding a weight to your chest during the exercise (2).

Hip Thrust:

Hip ThrustsHip thrusts are similar to the glute bridge but with weight involved in the exercise.  Begin with your shoulders higher on a couch or bench.  Place weights across your hips (preferably a barbell) starting in the seated position (See picture at right).  Press your hips towards the ceiling and hold at the top of the movement for 3 seconds then lower your hips to the starting position.  Remember to lower yourself slowly on the way down.  Perform 3 sets of 15 repetitions (2).

Time to hit the road with your new-found gluteal strength!

Picture 2

References:

1.    Kurz, T. Stretching Scientifically. Stadion Publishing Company, Inc 1994.

2.    Contreas, B. Dispelling Glute Myth. 2009. Available at: http://www.tmuscle.com/free_online_article/sports_body_training_performance/dispelling_the_glute_myth. Accessed January 23, 2010.

3.    National Strength and Conditioning Association. Essentials of Strength and Conditioning Conditioning. Human Kinetics. 2000.

4.    Thruston, J. Health Clubs Popular every January. 2010. Available at: http://www.post-gazette.com/pg/10014/1028048-55.stm. Accessed January 23, 2010.

5.    Cosca DD, Navazio F. Common problems in endurance athletes. Am Fam Physician. 2007 Jul 15;76

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