ITB Pain - Part 1
This is the first part in a three part series looking at Iliotibial band (ITB) pain. I've dealt with this painful injury myself, and have successfully treated many runners who have suffered from the condition. This series will explore the aetiology (causes) and treatment for effective management and pain-free running!
WARNING: While I've done my best to make this series interesting, it's been adapted from an excellent series by Prof Rich Willy. As such, it's slightly more information dense than some of our other posts - but persevere! Knowledge is power and the reward for your hard work is manifold! Of course, you could always book in with of our physios here and let us do the hard work for you if you prefer!
Figure 1. Factors relating to aetiology and recovery from ITB pain
What is Iliotibial Band Pain?
ITB pain is the main source of pain on the outside of the knee in runners, concerning between 5-14% of running-related injuries (14). It more commonly affects men; 50-81% of runners with ITB pain are male (14). Pain is localised over the lateral femoral condyle as the knee flexes and extends over an arc of 25-35 degrees of knee flexion, sometimes known as the “impingement zone” (10). Knee pain is reproduced as the hip extends while the knee flexes as the tensor fascia latae (TFL) musculature is loaded eccentrically (1), such as during downhill running or stair descent. Runners with acute ITB pain describe the pain as sharp and severe enough that cessation of running is necessitated.
Figure 2. A left knee passing through the "impingement zone".
ITB Pain and Training Load
"...an [ITB] injury will not occur without a [relatively] sharp increase in training load."
Figure 3. Runner A demonstrates a narrow step width pattern and Runner B demonstrates a high hip adduction running pattern. Both increase strain in the ITB
All running injuries are training load injuries - ITB pain is no exception. Runners who quickly escalate their total running volume (8) (especially downhill running [10]) are at risk for ITB pain. Running with a narrow step width (7) (as when running on a narrow trail) or running with higher amounts of hip adduction (4,9) increase strain in the ITB. Interestingly, a runner can have the aforementioned running biomechanics and relatively low tissue capacity, but an injury will not occur without a sharp increase in their training loads. Once injured, the runner’s load tolerance will decrease considerably and pain will then be felt during even comparatively gentle activities, such as going down stairs.
While not studied directly in runners with ITB pain, the presence of fear avoidance beliefs is a strong predictor of slow recovery from other non-traumatic knee pathologies, such as patellofemoral pain. (11)
Interesting Tidbit
The ITB Pain Cycle
Runners will frequently temporarily stop running when ITB pain occurs, causing the pain to decrease. Nevertheless, because the runner is avoiding loading the ITB (also known as stress shielding), the ITB and the runner unwittingly lose even more load capacity! So, when pain decreases, the runner can be tricked into believing their injury has healed. Runners predictably want to return to running ASAP, so the process is usually rushed giving way to the same training error that initially caused their injury! (see Figure 4).
Figure 4. Cycle of loss of load capacity
Diagnosing ITB Pain
There is no single test that diagnoses ITB pain! Diagnosis is instead based on patient history (i.e, recent relative increase in overall running volume and downhill running), but it is also a diagnosis of exclusion. Other sources of lateral knee pain should be excluded including:
- patellofemoral pain,
- gluteal tendinopathy,
- lumbar spine referral,
- and distal femoral stress fracture.
Imaging is typically only done to rule out other pathologies and is not particularly diagnostic for ITB pain (6).
ITB Pain Myths Busted
Figure 5. Cadaver showing the attachments of the ITB on a right knee.
What about the term "ITB Friction Syndrome"?
ITB pain is sometimes called ITB friction syndrome - however it seems this is a misnomer. The ITB is really just a thickening of the lateral thigh fascia and fans out with attachments to the femur and knee cap (patella) before finally attaching to Gerdy’s tubercle (see Figure 5) (2). The consistent tethering of the ITB to the lateral femoral condyle and supracondylar ridge
effectively prevents the ITB from flipping over the lateral epicondyle. In other words, no friction here (3). In the runner with ITB pain, the highly innervated fat (adipose) tissues that sit between the ITB and the lateral femoral condyle are compressed as the knee flexes past 30 degrees. This compression has potential to be painful (nociceptive) (2,3).
Oh, and while I remember, you can't stretch your ITB. It's physiologically impossible. Stop trying.
Lastly, hip weakness is not a predictor of who will develop ITB pain. Interestingly, individuals with ITB pain DO have hip weakness (14). This suggests that ITB pain causes hip weakness rather than hip weakness causing ITB pain. Intriguingly, Fairclough and colleagues (2006) hypothesised that compression of the highly innervated (lots of nerve endings) soft tissue between the ITB and the lateral femoral condyle results in inhibition of the proximal musculature (think, glutes!), resulting in a maladaptive strategy to minimise compressive forces acting on the tissue beneath the ITB (3). Nevertheless, hip strengthening seems to be a good idea when rehabbing ITB pain (more on this later!).
Click here for part 2 of this series!
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References:
1. Baker RL, Souza RB, Fredericson M. Iliotibial band syndrome: soft tissue and biomechanical factors in evaluation and treatment. PM&R. 2011;3:550-561.
2. Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of anatomy. 2006;208:309-316.
3. Fairclough J, Hayashi K, Toumi H, et al. Is iliotibial band syndrome really a friction syndrome? Journal of Science and Medicine in Sport. 2007;10:74-76.
4. Hamill J, Miller R, Noehren B, Davis I. A prospective study of iliotibial band strain in runners. Clinical Biomechanics. 2008;23:1018-1025.
5. Hreljac A. Impact and Overuse Injuries in Runners. Medicine & Science in Sports & Exercise. 2004;845-849.
6. Lavine R. Iliotibial band friction syndrome. Current reviews in musculoskeletal medicine. 2010;3:18-22.
7. Meardon SA, Campbell S, Derrick TR. Step width alters iliotibial band strain during running. Sports Biomech. 2012;11:464-472.
8. Messier SP, Edwards DG, Martin DF, et al. Etiology of iliotibial band friction syndrome in distance runners. Med Sci Sports Exerc. 1995;27:951-960.
9. Noehren B, Davis I, Hamill J. ASB Clinical Biomechanics Award Winner 2006. Clinical Biomechanics. 2007;22:951-956.
10. Orchard JW, Fricker PA, Abud AT, Mason BR. Biomechanics of iliotibial band friction syndrome in runners. Am J Sports Med. 1996;24:375-379.
11. Piva SR, Fitzgerald GK, Wisniewski S, Delitto A. Predictors of pain and function outcome after rehabilitation in patients with patellofemoral pain syndrome. Journal of rehabilitation medicine. 2009;41:604-612.
12. Rathleff MS, Rathleff CR, Crossley KM, Barton CJ. Is hip strength a risk factor for patellofemoral pain? A systematic review and meta-analysis. Br J Sports Med. 2014;48:1088.
13. Rosenthal MD. Clinical testing for extra-articular lateral knee pain. A modification and combination of traditional tests. North American journal of sports physical therapy: NAJSPT. 2008;3:107.
14. van der Worp MP, van der Horst N, de Wijer A, Backx FJ, Nijhuis-van der Sanden MW. Iliotibial band syndrome in runners: a systematic review. Sports medicine. 2012;42:969-992.
15. Willett GM, Keim SA, Shostrom VK, Lomneth CS. An anatomic investigation of the Ober test. The American journal of sports medicine. 2016;44:696-701.
