Iliotibial Band (ITB) injury By Will Dao
Do you have pain on the outside of your knee with walking, running or cycling and does it get worse when going up or downhill? You may be suffering from an ITB injury.
ITB injuries are one of the most common overuse injury of the knee. It is also common in cyclists and can occur in weightlifters, skiers and soccer players. The ITB is a thick band of fibrous connective tissue that runs along the outside of the thigh from the pelvis to the knee cap and shin bone. It runs over both the hip and knee joints. The ITB extends from the Tensor Fascia Lata (TFL) and Gluteus Maximus muscles in the hip.
What does the ITB do?
The ITB and the associated muscles assists in stabilising the knee through its range of movement but particularly during the stance phase of walking and running. It also contributes to abduction (outward movement) of the hip/leg and resists torsional movements around the knee joint.
ITB injuries can cause pain anywhere along this structure but it is generally most tender over the lateral femoral epicondyle which is the bony prominence just above the knee joint on the outside. The pain is often described as a sharp, burning type pain when aggravated or pressed on. Pain usually occurs shortly into activity and progressively worsens as one continues their aggravating activities. It is generally particularly worse with downhill and slow long distance running. There can be some swelling over the outside of the knee but this is not always the case.
How and why does this happen?
ITB injuries were traditionally explained as a failed healing response of the body from repetitive rubbing or friction between the ITB and the lateral femoral epicondyle as the band rolls over the epicondyle. However, more recent research is suggesting that the band is compressed against the epicondyle rather than rubbing over it. Pain can be caused by the compression of a bursa (fluid filled sac that cushions tendons from rubbing against bone) in this area.
Being an “overuse” type of injury, ITB injuries are usually caused from a sudden increase in loaded type of activities such as running, cycling, jumping, hiking etc.
- Increase in intensity, frequency and volume of training. For example, a dramatic increase in kilometres, an increase in hill runs or speed and a change in running surfaces.
- Weakness of the gluteals (primarily the gluteus medius and minimus muscles) or hip abductor muscles. The TFL muscle will often become more active to compensate for the weakness and can potentially put greater tension on the ITB (Hip Abductor
- Weakness in Distance Runners with Iliotibial Band Syndrome (Fredricson et al. 2000)
- Poor muscle flexibility in the hip flexors, quadriceps and TFL muscles
- Poor movement control and biomechanics and kinematics. Particularly with hip adduction and knee internal rotation with running (inwards rolling of the knees and hips (Noehrena et al. 2007)
- Poor foot or pelvic control
- Excessive hill training (particularly downhill)
- Worn out or unsuitable running shoes
What can we do to help you get fixed and stay fixed?
Have you been told that you have a tight ITB and hence just need to “stretch it out or roll it out”?
A tight and painful ITB is generally just the symptom. Successful management involves addressing the cause rather than the symptoms themselves.
Simply resting, to wait and see won’t work. Symptoms may reduce temporarily but once you run at the same level or intensity again, pain will return.
What to expect?
Diagnose and work out the causes of your particular ITB injury. Everyone is different and it is not always the same cause.
Aid with pain management which may include some or all of the following:
1. Activity modification – It is about relative rest and not actually avoiding all activities. We want to try to relatively unload the ITB.
2. Manual therapy (hands on treatment) to normalise muscle and joint flexibility
3. Foam rolling/stretches
4. Dry Needling
5. Rigid sports taping or Kinesio taping
6. Specific exercises and biomechanical retraining to strengthen and stabilise the hips, knees and legs.
7. Technique or sports specific retraining
How long will it take to get better?
ITB injuries can take 6-8 weeks prior to return to sports if the problem was detected early and it is managed well. However, from what we see, this condition tends to linger for much longer than the 6-8 weeks because many people leave it and deal with it themselves until it bothers them or limits them to the point where they finally feel they need help. This will certainly prolong the problem. It can take up to 6 months to return to pre-injury level of sports. Studies have shown that 92% of those suffering from ITB injuries should be back to sport at 6 months (Beals & Flanigan, 2013).
Do I need injections or surgery for this?
Given the current thinking that the pain is caused by the compression of a bursa, cortisone (steroidal anti-inflammatories) injections into the bursa by a Sports Physician may help alleviate the pain. This should not be the first port of call and should only be considered if there are absolutely no response to conservative measures and following the correct advice.
Surgery is only considered in severe cases where Physiotherapy and all other conservative measures have failed over a period of at least 6 months. It may assist in alleviating the pain. It should be seen as the absolute last resort as there is not much long term follow-up on the success of ITB release/lengthening surgery. There is also some research suggesting that surgery only has an 85% success rate. Nonetheless, post-operative rehab is still required to give someone the best chance to return to sport.
1. Fredericson, Michael MD*; Cookingham, Curtis L. MS, PT*; Chaudhari, Ajit M. MS†; Dowdell, Brian C. MD*; Oestreicher, Nina BS*; Sahrmann, Shirley A. PhD, PT‡ Clinical Journal of Sport Medicine: July 2000 – Volume 10 – Issue 3 – pp 169-175
2. ASB Clinical Biomechanics Award Winner 2006: Prospective study of the biomechanical factors associated with iliotibial band syndrome. Brian Noehrena, Irene Davisa, c, Joseph Hamillb a Department of Physical Therapy, University of Delaware, 301 Mckinly Laboratory, Newark, DE 19716, USA b Department of Exercise Science, University of Massachusetts, Amherst, MA 01003, USA c Drayer Physical Therapy Institute, Hummelstown, PA 17111, USA Received 10 April 2007, Accepted 17 July 2007, Available online 28 August 2007
3. Corey Beals and David Flanigan, “A Review of Treatments for Iliotibial Band Syndrome in the Athletic Population,” Journal of Sports Medicine, vol. 2013, Article ID 367169, 6 pages, 2013. doi:10.1155/2013/367169
If this sounds like your injury, don’t wait! Let a qualified health professional run through a thorough assessment and lead you in the right direction to get it fixed! Book your appointment online at https://www.fixphysio.com.au or call us on (02) 9231 0420