Iliotibial Band Friction Syndrome

Introduction
 
For the distance runner (and cyclist for that matter), a sharp, burning pain on the lateral aspect of the knee frequently signals Iliotibial Band Friction Syndrome (ITBFS).  Of all running-related overuse injuries, ITBFS accounts for about 12% and is certainly the most common cause of lateral knee pain.  Recognition of the condition is the easy part, but if poorly managed it can be recalcitrant, frustrating, and devastating to the athlete preparing for an event or simply trying to stay fit.  It needn’t be, so let’s shed some light on what it is, the causes, prevention and management.
 

Anatomy and Pathology
 
The iliotibial band runs down the outside of the thigh from the hip to the knee, with its main muscular attachments being the gluteus maximus and tensor fascia latae muscles (figure 1).  It crosses the knee and attaches to the tibia (lower leg), so that every time we flex and extend the knee, it flicks over the lateral epicondyle of the femur.  In English, it rubs across the part of the knee that sticks out. This constant rubbing can eventually lead to inflammation and pain on the outside of the knee, which usually gets worse the further you run or ride.  While it responds well to rest as the inflammation settles, it will usually return as mileage increases unless some important changes are made.
 

Causes
 
The two main causes of ITBFS are training/equipment errors and poor biomechanics.
 
Training/equipment errors

1. Rapid increase in distance covered
2. Training on crowned roads or paths
3. Excessive time on the track
4. Poor footwear which allows excessive and prolonged pronation of the foot
5. Worn out footwear…as a guide, most shoes are good for about 800km or 6 months

Biomechanics (THE BIG ONE!)

1. Runners with ITBFS exhibit poor biomechanics as a result of muscular weakness and inflexibility.
2. Studies have revealed poor strength and endurance of the gluteus medius muscle in runners with ITBFS.  When the gluteus medius is weak, or packs it in half way through a run due to poor endurance, two things happen.  The pelvis drops down on the side opposite the standing leg and tightens the entire ITB.  Also, the thigh rolls inwards and the ITB flicks over the lateral epicondyle with more ferocity.
3. Weakness of the hamstrings and quadriceps musculature has also been demonstrated when compared to the unaffected leg. 
4. Tightness and restriction in the ITB itself can be a factor, increasing the pressure and friction over the epicondyle at the knee.  Almost always, a tight ITB is associated with poor gluteal function.

Prevention
 
Prevention involves addressing any of the potential causative factors that may apply to you, and being smart about your training.

1. Start with your footwear, ensuring you’re shoes are right for you…and this doesn’t mean the most expensive pair that the kid at the local sports store is trying to flog!  If you’re a serious runner, have your foot assessed by a knowledgeable physio or sports podiatrist.  They can recommend a few appropriate models from which you can select the most comfortable.  Also, don’t let your shoes run past their used by date.
2. Moderate your increases in mileage and allow yourself adequate rest.  Running fatigued will alter your normally good form and result in injury.  Total mileage probably shouldn’t increase by more than 10% per week.
3. Don’t spend too much time on the track or running the same direction on cantered roads/paths.  Variety is the spice!
4. Maintain the strength and endurance of your gluts and get into the gym for quads and hamstring strengthening…and stretch that ITB.
   
   

Management Page
 
Your physiotherapist or sports medicine physician will guide you through the management of ITBFS, but your rehabilitation should look something like this.  Other stretches and strengthening exercises may be required based on expert assessment.

Phase I (Acute)
Activity modification – PAIN means stop!

1. stop running temporarily
2. arm bike, swimming, upper body weights, core strengthening for general conditioning

Ice massage
  NSAID’s (eg. ibuprofen, topical creams)
Taping (consult physio)
Corticosteroid injection (if not settling)
 

Phase II (Sub-acute)
Deep tissue massage (ITB, gluts, lateral quads)
Foam roller
Patellar mobilizations
Stretches

1. ITB/Tensor Fascia Latae
2. anterior hip
3. peroneal nerve

Phase III (Recovery)
  Strengthening/endurance

1. posterior gluteus medius
2. quadriceps
3. hamstrings

Orthotics/footwear modification as required

Phase IV (Return to Running)

1. Short sprints
2. Gradual PAIN-FREE increase in distance/frequency/hills
3. Modification of running style (based on assessment) and training errors

Stretches
 

1.    Iliotibial Band/Tensor Fascia Latae – 3 x 30 seconds, twice daily + after running
 
Figure 2.  The leg to be stretched should be placed behind the opposite leg, and held in an externally rotated position (toe out).  The hip joint should also be kept in as much extension as possible as the pelvis is moved towards the wall.
 

 

2.    Anterior Hip – 3 x 30 seconds, twice daily + after running
 
Figure 3.  Lying on the floor, the knee is bent up and out so the foot is placed just below the opposite knee.  The buttock should be tightened and the leg pushed down and out along the thigh so the front of the hip moves closer to the floor.
 
 

3.    Peroneal Nerve – 1 x 20 repetitions, daily
 

Figure 4.  Sitting with the feet off the floor, the body is slumped forwards and the chin taken to the chest.  With the toes pointed down and in, the knee is straightened until a gentle pull is felt.  Only hold for a second and then release, teasing into the stretch with each oscillation.

 

 

Strengthening

1. Posterior Gluteus Medius – 3 x 30 seconds, twice daily

Figure 5. Standing on one leg, with opposite knee lightly touching the wall for balance. Keep the foot parallel to the wall, and the hips and shoulders pointing straight ahead. Turn the knee and thigh outwards, away from the wall, by squeezing the buttock muscle, and hold as hard as you can for full 30 seconds.

 

 

 

2. Quadriceps – 3 x 15 repetitions, twice weekly

Figure 6. Eccentric Leg Press - Push the plate up with both legs until the knees are almost straight, then slowly lower with one leg only.

 

3. Hamstrings – 3 x 15 repetitions, twice weekly

Figure 7. Eccentric Hamstring Curls – Curl the bar up with both legs, then slowly lower using only one leg.