Iliotibial Band Syndrome

This is one of the most common, and often most frustrating, running related injuries. It is also easily treated if diagnosed and treated early before it becomes chronic. This is one condition that often responds well to chiropractic treatment because of the relationship between the pelvis and the muscles that attach to the pelvis. If someone has faulty pelvic mechanics (i.e.- maybe the joints are jammed a bit and they don't allow for normal pelvic movement) then the muscles that attach to the pelvis will not work as efficiently. If they pull at a slightly different angle, they'll often get tight and sore. Stretching helps, but it doesn't last.

The Anatomy (images)

The Iliotibial Band (ITB) [also known as the fasciae latae] is a thickening of the fascia, or the outer casing of the muscle, that runs up the outside of the thigh. Fascia is like a sausage casing and the ITB is a thickening of that sausage casing. It originates up by the top of the hip and ends on the outside of the knee. You can feel your ITB when you stand. It causes the outside of your thigh to become very firm and tight while your thigh muscles remain more relaxed. In fact, that's one of the reasons we have an ITB - it holds our legs straight when we stand, thereby allowing the bigger thigh muscles a chance to rest.

The two main muscles that are addressed when dealing with ITB syndrome are the Gluteus Maximus (the buttock muscle) and the Tensor Fasciae Latae (TFL) muscles. The TFL muscles is just a little guy but it does most of the work while we stand, thereby allowing the big guys to rest. You will sometimes hear ITB syndrome referred to as TFL syndrome - the two terms are synonymous.

Signs and Symptoms

  • Lateral (outside) knee pain - NOTE - very few conditions, other than a ligament sprain, will present as lateral knee pain therefore this alone is often diagnostic.

  • Pain is often worse after running, especially after climbing hills and often aggravated by climbing stairs

  • Pain may not be present until mid-way through a run, often not until climbing a hill

  • Pain can literally bring a runner to his/her knees

  • Sometimes associated with a 'snapping hip', in which the muscles that cross the outside of the hip can be felt to snap or click during walking or running.

  • Pain may also present as lateral thigh pain more so than knee pain but is rarely focused primarily in the hip or gluteal muscles.

  • Can often be attributed to some form of over-training - doubling one's mileage, sudden increase in hill repeats, etc.

What's Going On

The lateral knee pain is being caused by the ITB pulling up on it's insertion on the outside of the knee. Underneath the ITB near it's insertion at the knee is a bursa. Bursae are fluid filled sacs that lubricate areas where rubbing and friction occur. When that ITB was pulled tight it put too much pressure on the bursa and that bursa reacted by becoming inflamed and swollen, giving you pain.

The ITB was pulled tight by one of the two muscles mentioned above - the TFL or the Gluteus Maximus. Running up hills, for example, uses more of the glutes than running on flat ground, therefore it will often trigger a bout of ITB pain. That also explains why the pain is often aggravated by hill repeats. The ITB can also be aggravated by running on uneven roads or on tight indoor tracks, running in poor running shoes or if your foot pronates (arch collapses).

If there was an underlying problem with pelvic mechanics (see Introduction for more detail), this may have contributed to the ITB problem. Just think about it! You run with both legs equally - why would one leg get ITB pain and not the other?

What To Do About It

First off, if you have faulty pelvic mechanics you'll have a lot of trouble getting rid of ITB pain on your own. Stretching probably won't do it alone. So, if you've been dealing with ITB for more than 2 weeks with just stretching, ice, exercises, etc. and you're not improving much, have a chiropractor check your pelvic mechanics.

We have seen numerous patients who have tried TFL stretching, ice, ultrasound, etc. over the outside of the knee with little success. That's because the problem is not at the insertion in the knee - that's just where the pain is! The problem is higher up. And with that said, it's also important that you remember which muscle is the bigger of the two and which muscle works more when we climb hills. The Gluteus Maximus is often overlooked as a major contributor to ITB Syndrome. I can't count the number of patients I've seen who didn't improve until they started stretching their Glute Max as opposed to just the TFL. Anyway, here's a useful plan in a nutshell.

  • Address faulty pelvic mechanics

  • Reduce or stop running (especially hills) until pain has disappeared. Maintain fitness with cycling, water running, roller blading or any other activity that does not increase symptoms

  • Use ice over outside of the knee when pain is severe

  • Stretch the Glutes and TFL muscles (see Stretching for more detail)

  • Self-massage over the outside of the thigh, or deep massage of the glutes is also useful

  • Use hot tubs or Epsom Salt baths to loosen the muscles before stretching.

  • Address any potential faulty foot mechanics (pronation), get the right pair of running shoes for your foot and/or orthotics

  • Return to running gradually. Build up slowly to pre-injury training level. Add hills gradually.

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