The iliotibial band can be a major source of problems for many runners. Even mentioning that structure can strike fear in the hearts of athletes in many sports, especially distance running. This structure is actually very unique and provides a great deal of stability to the knee and lower extremity. The structure itself is not usually what causes the problems. It is far more often that the structure is being abused by the individual it is on!
ANATOMY
Image from web.duke.edu
The iliotibial Band (or tract) is a fibrous band of tissue on the lateral aspect of the femur. Both the tensor fascia latae and the gluteus maximus attach to it at the hip. The band then travels down to Gerdy's tubercle on the lateral knee.
BIOMECHANICS
The iliotibial band is a unique structure. It stabilizes knee in both when it is in extension and slight flexion. Thus, the band will be pulled taught through the early part of stance phase, especially at initial contact and may be pulled tight again as the runner's lower extremity goes behind them. This makes sense as the tensor fascia latae and glute max are known to work to stabilize the femur, which is half of the knee joint. The iliotibial band is an extension of those two muscles and thus may aid in some minor degree in flexion and extension of the lower extremity. The primary function is to stabilize the lateral knee, especially given that both the muscles that insert upon it are major abductors of the hip.
ILIOTIBIAL BAND SYNDROME
Image from Move Forward PT
Iliotibial band syndrome and pain will usually occur first during the initial contact phase of gait in about 20-30 degrees of knee flexion (Orchard, Fricker, Abud, Mason, 1996). Research has demonstrated those with iliotibial band issues many times have weak hip abductors and external rotators (Aderem & Louw, 2015; Noehren et al., 2016). Additionally further research has also demonstrated increased hip adduction and internal rotation as further biomechanical markers of this issue (Ferber, Noehren, Jamill, Davis, 2010). As the ITB is an extension of the TFL and glute max, going into excessive hip adduction will put strain on this fibrous band due to the function of trying to stabilize the lateral knee. The internal rotation aspect in my mind may suggest either a dominance of the TFL over the glute max or hip external rotator weakness as the anatomy of the hips usually play into internal rotation during joint loading (but this needs to be controlled muscularly).
EXERCISES
Given that the ITB is strained in runners who have excessive adduction and internal rotation, there is a need to strengthen the hip abductors and external rotators. Foam rolling may help short term but will not fix the problem (I will have a post on foam rolling in the future. The short version is that it likely affects your nervous system more than the structures you are rolling).
TFL Stretch
Although the TFL is a hip abductor, the fact that it is an internal rotator makes the overuse of the structure a possible source for iliotibial band syndrome. Keeping this muscle from getting overused and shortened is important in preventing excessive loading of the iliotibial band. For this reason, the above stretch is important as is the exact way you execute it. Make sure you put the leg that is being stretched far enough behind you into extension and adduction (the TFL is a hip flexor) with some slight external rotation. Yes the adduction component you would think would cause problems, but this will be taken care of by the performance of the exercises below. Addressing the internal rotation component of the TFL is more important.
Squat with Band
It is important to train the neuromuscular system and the muscular system to maintain a neutral knee position during squatting. Running is essentially a series of single leg squats, so double leg squats are a great place to start. The use of a band helps to facilitate the neutral knee position by reinforcing the hip external rotators and abductors. You should maintain constant tension through the theraband as you go down AND up.
Side Bridge
A powerful hip abductor exercise I picked up from Stuart Mcgill, The side bridge brings aspects of the traditional clamshell, adds a side plank/ core and a weight bearing component. This is a very easy exercise to cheat through, so make sure to squeeze your butt checks throughout the range of motion both up and down. If this is too hard, start with a static side plank first from your knees, then progress up to this.
Example of good mechanics versus mechanics that may play you at risk for ITB Syndrome. Notice the hip adduction on the photo on the right side.
Conclusion
The iliotibial band is a very important structure that helps to stabilize your lower extremity and helps extend the reach of some of your hip abductors. Make sure you keep it healthy! Unless you have biomechanical factors that increase your risk for internally rotated or adducted positions of the hip, femur and knee (femoral anteversion, coxa vara, tibial torsion, etc), iliotibial band syndrome is fairly simple if caught early. The above exercises however can be quite challenging to execute properly. Anyone can give you an exercise, only an expert can explain to do it correctly. If you continue to have trouble, please contact your local running physical therapist.
Thanks for reading and don't forget to tack on!
Dr. Matthew Klein, PT, DPT
Orthopedic Resident - Casa Colina
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References
Aderem, J. & Louw, Q. (2015). Biomechanical risk factors associated with iliotibial band syndrome in runners: a systematic review. BMC Musculoskeletal Disorders, 16: 356.
Middlekoop, M., Kolkman, J., Ochten, J., Bierma-Zenstra, S., Koes, B. (2007). Prevalence and incidence of lower extremity injuries in male marathon runners. Scandinavian Journal of Medicine and Science in Sports. doi: 10.1111/j1600-0838.2007.00683.x
Noakes, T. (2003). Lore of Running - Fourth Edition. Champaign, Il: Human Kinetics
Noehren, B., Davis, I., Hamill, J. (2007). Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clinical Biomechanics, 22: 951-956.
Noehren, B., Schmitz, A., Hempel, R., Westlake, C., Black W. (2014). Assessment of Strength, Flexibility and Running Mechanics in Men With Iliotibial Band Syndrome. Journal of Orthopaedic & Sports Physical Therapy, 44(3): 217-222
Orchard, J., Fricker, P., Abud, A., Mason, B. Bioemchanics of Iliotibial Band Friction Syndrome in Runners. The American Journal of Sports Medicine, 24(3): 375-379
Perry, J. (1992). Gait Analysis: Normal and Pathological Function. Thorafare, NJ: SLACK Incorporated.