What is iliotibial band friction syndrome?
The iliotibial band (ITB) is not a muscle but a thick band of connective tissue that stretches from the outside of the pelvis down past the knee joint to the outside of the shin bone (tibia). There are two muscles that insert into the band, the gluteus maximus and tensor fasciae latae. The ITB is important in providing lateral stability to the knee.
As the name suggests, there is a point of friction which can cause pain: as the knee straightens and bends during running the ITB can rub on the outside of the femur. This may lead to inflammation of the band or underlying tissue.
A common misconception is that the ITB is tight and that this is what causes the problems. There are people who do present with tightness, but this is often as a result of something more complex. So treating the tightness rarely makes the pain go away.
The ITB passes over the knee joint and so this can occur with other knee problems, such as issues with the cartilage. There is also a nerve that is called the peroneal nerve that passes very close to where the ITB inserts, and this too can be a source of symptoms in this area. So it is important to get an accurate diagnosis before thinking about what treatment is best.
What causes it?
As with exercise-induced leg pain, which I wrote about in my last blog, it is classified as an overuse injury. So the causes of ITBFS can be split into:
1. Training errors – eg too much too soon, insufficient recovery.
2. Altered biomechanics – relating to how the motion of running is controlled through the joints and muscles of the leg and pelvis.
Due to where the ITB attaches, a lot of people will present with some glute dysfunction. The angulation of the knee and the foot position can also make someone prone to getting ITBFS. Asymmetry in one limb compared to the other can be a risk factor, as with any over-use injury.
How to treat it?
It is great to have the opportunity to write this blog as I can finally say to a decent amount of people that using a foam roller will not cure ITBFS! There are a lucky few patients with ITBFS who come with good mechanics and no training errors and have just got tight and so do respond quickly to soft tissue release/foam roller. But the majority of people will present with a more complex mix of training errors and biomechanical problems.
The pain from ITBFS often starts with inflammation and this takes time to build up, so a lot of people only start to feel the pain after a run. The typical patient will report an increase in mileage and may have increased too quickly, not allowing their body to adjust. Once it starts it is very difficult to calm down. The mistakes a lot people make are trying to continue running and seeking help too late and/or believing that a foam roller will cure all evils.
Treatment mostly involves:
• Correcting biomechanical dysfunction.
• Temporary alteration of training that will often require a total break from running – otherwise it won’t settle.
The movement faults that a patient presents with – eg reduced glute activation or reduced stability at the pelvis – will form the basis of treatment. One of the tests we look at to assess someone’s movement is a single-leg squat. So this is something you can try: stand in front of a mirror and look at your pelvis and your knee and watch how they move as you perform a shallow single-leg squat. If your pelvis tilts downwards so your “belt line” is not level (this is sometimes difficult to spot) or your knee deviates inwards then you probably don’t have ideal mechanics. Of course, many people manage just fine outside of these “ideal” mechanics, but there is good evidence that links them to increased stresses and potential for injury in the lower limb. So the important thing is if you have pain and altered biomechanics together then this is something that should be corrected; otherwise leave well alone.
If conservative measures fail, then other types of treatment will be considered such as a steroid injection into the bursa (the sack of fluid that sits behind the ITB to prevent friction) if it is inflamed. But physiotherapy is the first line of treatment as an injection will only offer temporary relief, not solve the problem. As the initial source of pain comes from inflammation, it can often be useful to have a short course of anti-inflammatories. But again this will not solve the problem long term if the movement patterns stay the same.
So hopefully you can start to see why a foam roller is not a magic wand. In fact there are no magic wands with ITBFS. It is a difficult condition to treat and can often take some time to improve.
• Rebecca Christenson is a physiotherapist at Pure Sports Medicine. To get in touch, please visit www.puresportsmed.com or follow her on @rebchristenson
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