(This article by Matt Phillips originally appeared in Running Fitness Magazine, June 2014)
What Is ITB Syndrome?
ITB is an acronym for the Iliotibial Band – a long, thick piece of fibrous tissue (not muscle – see significance later on) which connects the gluteus maximus muscle and tensor fascia latae muscle of the hip (origin) to the tibia bone of the lower leg (insertion). Where it crosses the knee joint, the ITB passes over the outer end of the femur (thigh) bone, namely the lateral femoral condyle. Research suggests that the existence of a blood and nerve rich layer of fat underneath the ITB serves to protect it from the femoral condyle. Compression of this layer of fat against the lateral femoral condyle is thought to be the cause of the pain associated with ITB Syndrome.
What Causes The Compression?
If the ITB were a muscle, compression of the fatty pad could be explained by contractile changes. When muscles are overworked they can shorten, increase in size and end up pushing against other nearby tissues, especially if in a confined space (e.g. piriformis syndrome). In such cases, stretching, foam rolling and deep massage of the muscle in question can be used to help return it back to its optimum size. However, as we saw above, the ITB is not a muscle. It is an incredibly strong piece of connective tissue anchored along the length of the femur. Its length does not change. Research has shown that the most it can be “stretched” is about 2mm. Therefore, for the ITB to move and cause compression, there must be a change in the position of either its origin (where it starts) or its insertion (where it ends).
Origin Moving Away From Insertion
As stated earlier, the origins of the ITB are the gluteus maximus muscle and tensor fascia latae (TFL). As these are muscles, their length can change and in effect modify the positioning of the ITB. The TFL for example is thought to become overused in runners if the iliopsoas muscle is not being used sufficiently in hip flexion (lifting of the knee). This can cause the TFL to become shorter, moving the origin of the ITB away from the insertion. This is a common issue in ‘quad dominant runners’ and something which relaxation of the TFL (e.g. by foam rolling / massage) together with modification of running form can potentially help with.
Another movement pattern that causes a movement of the origin of the ITB away from the insertion is “Contralateral Pelvic Drop”. This refers to a dropping of the pelvis on the opposite side to the leg in stance phase (the one supporting the body weight), in other words on the same side as the leg in swing phase (off the ground), as seen in the screen shot taken during a gait analysis.
Contralateral Pelvic Drop is thought to potentially be caused by weakness in the gluteus medius muscle of the stance leg, which as a result allows the pelvis on its opposite side to drop more than the small amount needed for efficient gait. This drop on the swing phase side leads to a raising of the pelvis on the stance phase side, leading once again to the origin of the ITB moving away from the insertion. Appropriate strengthening of the glutes and gait retraining can be used to correct it.
Insertion Moving Away From Origin
The insertion of the ITB is the tibia bone of the lower leg, on the top outer condyle (commonly referred to as Gerdy’s tubercle). Relative movement here is very common in runners who exhibit an internal rotation and aDduction (movement towards the midline of the body) of the upper leg. Referred to as knee valgus (‘knock-kneed’), this is a very good example of how what happens at the hip can effect what happens in the lower leg and ultimately leads to the insertion of the ITB moving away from the origin (see image).
The most commonly cited reason for knee valgus in runners is weakness of the gluteus maximus and gluteus minimus, responsible for external rotation of the upper leg and aBduction (moving it away from the midline of the body). Identification of why these muscles are not being used efficiently followed by appropriate conditioning and modifications to running form can address this.
Traditional treatment for ITB Syndrome is very often based on ‘treating’ just the ITB band alone. In some cases, the ‘treatment’ employed makes no physiological sense, e.g. trying to stretch the ITB or relax it by further compression via foam roller or deep massage. Other remedies such as taking NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen, application of ice, use of kinesiotape – all of these may provide pain relief (which is an important part of rehab) but will not necessarily address the cause.
To help you get over ITB Syndrome and see it return next time you start building distance, your therapist needs to consider what is happening at the origin of your ITB. By doing this, they can work to identify movement patterns that may be causing the painful compression. Seeing how you run is imperative for a thorough assessment.
There is only so much a therapist can identify when you are lying down on a couch, and chances are the painful part you are having prodded may have little to do with the cause!