5 Key Treatment Principles for Iliotibial Band (ITB) Syndrome

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Written by: David Burnett, BScH, MScPT, Registered Physiotherapist

Introduction

Iliotibial Band (ITB) Syndrome is:

  • An overuse injury characterized by pain on the outside part of the knee
  • Pain can be experienced during activity or at rest with the knee bent
  • Common in runners but also seen in hikers and cyclists

 Pathology

  • Some debate over ‘friction’ and exact pathology
  • Likely some inflammation/irritation of connective tissue on the outside of the knee

Anatomy

  • ITB attached to gluteus max and tensor fascia latae (TFL), runs along the length of the femur and attaches to the lateral condyle of the tibia
  • Contributes to lateral knee stability
  • Very unlikely to be able to stretch it
  • May behave like a tendon in storing and releasing energy
  • Potential most vulnerable range is 30-40 degrees of knee flexion when ITB may cross lateral femoral condyle 

Unmodifiable Intrinsic Risk Factors

  • Age
  • Gender – although yet to be proven it is thought females have a higher likelihood of developing ITBS due to anatomical differences
  • Genu varum (Bow leggedness)
  • May overlap with anterior knee pain/patella femoral pain syndrome

Modifiable Intrinsic Risk Factors (*Best evaluated by a Physiotherapist*)

  • Reduced control of hip adduction/internal rotation
  • Reduced glute med strength
  • Biomechanical abnormalities – foot alignment/pronation
  • Weight (Increased BMI)
  • Muscle imbalance and inflexibility
  • Leg length discrepancy (LLD)
    • A true LLD can be modified with appropriate foot lift orthotic
    • A functional LLD can be modified with better muscular control and/or orthotics if necessary

Extrinsic Risk Factors (*Best evaluated by a Physiotherapist*)

  • Change in loading
    • Return to running or activity after a break
  • Training errors
    • Change in training type (i.e. increased downhills for runners and hikers)
    • Increase in training volume/intensity too quickly
    • Change in training duration
    • Increase in training frequency
    • Change in weekly distance
  • Running style
    • Narrow step width
    • Slower cadence
  • Footwear – if not supportive enough to prevent over pronation

Treatment Principles

  1. Identify and address potential causes (i.e. intrinsic and extrinsic factors)
  2. Reduce pain
  3. Strengthen glute med
  4. Improve kinetic chain control as a whole
  5. Gradual return to activity

Pain Reducing Tips

  • Initial relative rest and ice
  • NSAIDs – discuss with family doctor
  • KT tape – see instructions below

You will likely need a partner to do the tape job. Lie on your unaffected side with knee relaxed down on bed and flexed to 60 degrees. Find your pain site. This will be the central point of your tape job. Cut an I-strip about 6-8 inches long. Rip the paper in the middle of the KT tape (as shown). Without any tension on the tape place the middle portion of the tape over your pain site. Without any tension place the remaining tape down following the line of your leg.

Hands holding KT Tape

Next cut 2 small I-strips around 3-4 inches long. Rip the paper in the middle of the KT tape. With full tension on the tape place the middle portion of the tape over site of pain. Orient the tape to form an ‘X’ pattern over the pain site.  Without any tension on the ends place them down.

Knee with KT tape
Knee with KT tape
  • Self-massage of glutes and ITB – not the site of pain – can use a tennis ball or foam roller
  • You may still be able to run, bike or hike!! BUT avoid activity that pushes pain past a 2/10 and does not settle within 24 hours
  • Potential modifications to keep pain down during rehab
    • Slightly increase step width
    • Keep hip, knee and foot aligned during activity – prevent knee from ‘turning in’
    • Cut back on downhill activities if hiking or running
    • Perform activity every other day
    • Change activity to pain free swimming, walking, or biking
    • If running – increase cadence by 5% and build up to 10%
    • Perform strength training and activity on separate days
    • Gradually increase activity as pain allows
    • Monitor pain response after activity – keep pain below 2/10 – find the sweet spot between no activity and too much
  • Wear good supportive running or hiking shoes for activity

Exercises – Improving glute med strength and kinetic chain control

***Note: These are not recipe exercises but rather examples – see your Physiotherapist for an individually tailored, appropriately graded exercise program!

Side Leg Raise

Lie on your unaffected side. You can slightly bend the bottom knee to maintain balance but it is not necessary. Keeping your affected leg straight, slightly extend your hip and raise it to about 30 degrees, then lower, repeat. It is important to make sure you do not open your hips and roll backwards during this exercise. If this occurs you will feel this exercise working the front of your hip – you should feel it working in your butt. Perform 3 sets of this exercise to fatigue (when you feel a burning in your butt).

You can progress this exercise by placing an exercise band around your ankles to increase resistance.

Side leg raises on carpet

Monster Walks

Place a mini-band around the thighs, just above the knee or around the lower leg near the ankle. Get into an athletic position with knees slightly bent, butt back and back straight. Take a step sideways using your abductors (gluteus medius), without rotating at the hips and keeping toes pointing forwards. Keep the band taut throughout the entire duration of the movement. Repeat 10 steps to the left or right and back. Perform 3 sets of this exercise to fatigue (when you feel a burning in your butt).

You can progress this exercise by increasing band resistance strength.

Monster walk with band
Monster walk with band

Single Leg Squat against the Wall

Stand sideways against a wall with your unaffected leg against the wall. Bring the unaffected leg up to approximately 45 degrees hip flexion.  Keeping your back straight, slowly sit back as if you are sitting on a bar stool behind you to about 30 degrees of knee flexion. During this movement be sure to keep your hip, knee and feet in line and your knee stable. Return to the standing position and repeat. Aim to perform 3 sets of 6-12 reps with good form.

The progression of this exercise is a single leg air squat performed with good alignment.

Knee with KT tape
David Burnett, BScH, MScPT
Registered Physiotherapist

David joined GRSM in July 2016. He graduated with his MScPT from Leeds Beckett University and BSc Biomedical Sciences from the University of Waterloo, while playing for the Warriors Men’s basketball team.

David has completed his level 3 FCAMPT training and is also certified in Integrative Dry Needling, which is used to release muscular restrictions throughout the body.

David enjoys working with high level athletes from all sports. In particular, he has extensive experience training and rehabilitating basketball athletes.

He also specializes in comprehensive gait analysis for both experienced and inexperienced runners. He has completed several courses including Tom Groom’s in depth Running Repairs.

David played semi-professional basketball in Nairobi, Kenya after University and previously worked as a Sport and Fitness Director in Sydney, Australia. In his free time, David enjoys keeping active outdoors, going to the gym, and playing any and all sports.

Now Open for In Clinic and Virtual Appointments at GRSM

Your safety and health and that of our GRSM staff is of the utmost importance to us. To operate our clinic as safely as possible, we have put strict processes in place. 

We will be gradually and carefully opening our clinics starting on Monday, June 1, 2020.

To request an In-Clinic appointment, please click link below or email the clinic on our Contact page.

Virtual appointments are still available!

Resources

Brindle, R. A. (2018). Physiological and Biomechanical Factors Contributing to the Hip Adduction Angle in Female Runners (Doctoral dissertation, Drexel University).

 

Fairclough, J., Hayashi, K., Toumi, H., Lyons, K., Bydder, G., Phillips, N., … & Benjamin, M. (2007). Is iliotibial band syndrome really a friction syndrome?. Journal of Science and Medicine in Sport10(2), 74-76.

 

Fredericson, M., & Wolf, C. (2005). Iliotibial band syndrome in runners. Sports Medicine35(5), 451-459.

 

Fredericson, M., Cookingham, C. L., Chaudhari, A. M., Dowdell, B. C., Oestreicher, N., & Sahrmann, S. A. (2000). Hip abductor weakness in distance runners with iliotibial band syndrome. Clinical Journal of Sport Medicine10(3), 169-175.

 

Tiu, T., & Craig Van Dien, M. D. Knee overuse disorders.

 

Meardon, S., & Miller, R. H. A new approach to iliotibial band syndrome in runners.

 

Meardon, S. A., Campbell, S., & Derrick, T. R. (2012). Step width alters iliotibial band strain during running. Sports biomechanics11(4), 464-472.

 

Miller, R. H., Lowry, J. L., Meardon, S. A., & Gillette, J. C. (2007). Lower extremity mechanics of iliotibial band syndrome during an exhaustive run. Gait & posture26(3), 407-413.

 

Nielsen, R. O., Nohr, E. A., Rasmussen, S., & Sørensen, H. (2013). Classifying running‐related injuries based upon etiology, with emphasis on volume and pace. International journal of sports physical therapy8(2), 172.

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