For 10 years, an article on a treatment for iliotibial band syndrome (ITBS) by podiatrist and competitive runner Brian Fullem has remained one of the most popular on our website. Here Fullem revisits the topic, adding new exercises he’s learned or developed that address the underlying issues better than ever.
ITBS remains one of the main causes of knee pain in runners. The IT band, or ITB, as it is commonly known, can become so painful that a runner is unable to train at all.
Mark Fadil, now director of Sports Medicine Institute International (SMI) in Palo Alto, California, knows this injury personally and professionally. As a high school senior in 1991, Fadil won the New York state 3200m championship in 9:10. After one successful collegiate year, Fadil developed pain on the outside of his knee on the fourth day of his sophomore season.
He was diagnosed with ITBS and, even though he was receiving regular treatment–including NSAIDs, ultrasound, stretching and two cortisone injections–the pain progressed to the point that he could not even run a mile. Nine months later, he turned to renowned Irish physiotherapist Gerard Hartmann, and after 11 days of deep-tissue massage, stretching and strengthening, he was able to train again, finishing his career at Stanford University as a team captain with an 8:50 best in the 3,000m steeplechase.
“You need to address both the cause and the symptom,” Fadil says. Fortunately, we now know more about the causes, and hopefully runners can prevent the problem earlier.
WHAT IT IS, WHAT GOES WRONG
The ilitotibial band is a fibrous structure that assists the stability of the leg during the stance phase of the stride, works with the hip muscles in abduction (outward movement) of the thigh, and helps to resist torsional movements around the knee joint. The ITB begins in the hip as the tensor fasciae latae muscle and ends below the knee joint, inserting into the tibia at a bump known as Gerdy’s tubercle.
When the ITB becomes stressed through repetitive overuse, runners most commonly feel pain in the lateral (outside) portion of the knee, above where the ITB crosses the joint. This condition is sometimes accompanied by a clicking sensation, caused by the ITB snapping across the joint. The pain usually occurs just after heel contact and gets progressively worse as the run goes on. Downhill and long, slow running tend to cause an increase in symptoms.
ITBS typically starts with tightness on the run and often advances to the point where the pain is debilitating. While the ITB will become tighter when it is injured or overstressed from excessive training, this tightness is not the root of the problem. The cause of this injury lies in the function of the ITB and weakness surrounding it.
The ITB is not a strong structure; any weakness in the surrounding muscles can lead to injury. Runners are notoriously weak in their hip and core muscles, particularly if they haven’t done any strength training or participated in sports that involve side-to-side movement.
In 2000, Michael Fredericson, a doctor at Stanford University, discovered that weakness of the hip abductor muscles (mainly the gluteus minimus and gluteus medius) was the leading cause of ITBS. Research in the interim has only served to prove that Fredericson was correct in his original assumptions. In 2007, Brian Noehren, Irene Davis and Joseph Hamill reported in the journal Clinical Biomechanics that studying 3D kinematics of female runners revealed those who develop ITBS have an increased hip abduction motion, along with greater knee internal rotation, both likely caused by weakness in the hip abductors.