Steve Smith’s Blog

IT Band Syndrome

If you have been a runner for any length of time at all, then you have no doubt heard of “Illiotibial band” or “IT band” syndrome. If you haven’t had it yet, then you probably know someone who has. Of the five most common running injuries, Illiotibial band syndrome ranks number one. This problem is often seen in marathon training programs that take you from the couch to the finish line in just 5 months. Unfortunately, the problem tends to show up late in the training after the runner has done the first 14 or 16 miler. The problem is most often first noticed on the short recovery run following a high miler. This is often baffling, since the runner did well on the big run and can’t connect the problem with the cause. The recommendation for rest is never well-received and bedevils a training schedule that has even longer distances in the coming weeks. Rest has the dual outcome of helping the problem and causing a training gradient that is too steep. If you miss the next long run, say a 16 miler, then you’ll be going from the 14 miler that caused you the problem, to an 18 miler that will surely leave you in a sorry condition.

Having laid out the training problems associated with IT band syndrome; let’s take a look at the symptoms, causes and solutions.

Here’s what it feels like:

  • The pain is on the outside of the knee, at the bony area just above the joint and usually feels like a deep burning ache while running.
  • The pain is worse when going down hills or stairs. Downhill pain may persist after the run.
  • The pain usually stops, shortly after the run.
  • Subsequent runs result in an earlier onset of pain, which may also be more intense.

What is the cause?

Theories are abundant, as are solutions, leaving the subject open to a lot of opinions and therefore gurus of the realm. Having said that, I will substitute the literature with my own observations of runners who have IT band syndrome.  To understand the problem let’s take a look at how your body moves while running. Running is a one sided activity, only one foot is in contact with the ground at a time. When your foot strikes the ground, you are in essence balancing on one leg while the other half of your body is suspended in space. The muscles that hold you in this position are the gluteals, psoas, abs, and a small muscle on the side of your hip called the tensor fascia latae. If any of these muscles are weak, your hip will drift too far lateral and over stretch the Illiotibial band. This isn’t usually a problem when running short distances, but when you tire on a long run, the muscles fail to hold your form and that’s when the trouble begins. As your knee passes back and forth under the overstretched IT band, the bony prominence plucks it repeatedly and creates pain and inflammation at the attachments.

The second biomechanical factor is that your knee tends to twist just a little bit when you are running. This causes the IT band to pluck over the outside of the knee. The twist occur somewhere between the time the heel strikes and when you push off with the toe.  There are a few variations of how the foot strikes the ground and various schools of thought on exactly how this should occur. I have seen athletes of all styles who are very competitive and injury free.  Observation of sprinters quickly reveals a definite tendency to run on the toes, in order to engage the springy calf muscles. Some of the wackiest looking gait patterns cause no apparent injuries. In general though, if your foot rolls inward too much, it will cause trouble. This is especially so with endurance athletes.

Prevention and treatment:

Exercises that strengthen your gluteal muscles, tensor fascia latae, and core should be your first line of defense. I have found it nearly impossible to explain exercises inside of an article in a comprehensible manner. Drawings and photographs only add to the confusion. Even face to face coaching can be difficult to teach the exercises. I have noticed that teaching the exercises and stretches to those who most need them are the same people who have the most difficult time learning them. I have videotaped the exercises that work the best and you can view them here. These are not the only exercises that work – there are others but I have had great success with these. The 3 point touch is the best all around exercise, followed by the side plank and abdominal strength. The abdominals can be tricky if you have a sensitive back so I have left out some of the more effective methods. If you’re a new runner and I highly recommend that you start these exercises right now- to prevent having problems in the first place.

Cross training on a bike, roller blading, or strength training in the gym almost completely eliminates the risk of having the problem. Start cross training early and you will complete your training without the risk of IT band problems.

If you are an experienced runner who has a recent onset, then think about getting a new pair of shoes. If those shoes you have been wearing have lost their pizzazz and your gait muscles can’t control your feet from excessive roll- in, then your legs will twist too much. Sometimes that is all it takes, new shoes. This is the best case scenario, since almost all runners love new shoes and avoiding pain is a natural survival instinct. If you are new to running and you already have new shoes then a pair of those off the shelf orthotics might help. There is an  80% chance that the store bought orthotics will work, when compared to the custom made, “ExpenseMaster Nine Thousand Deluxe” model made by your local health care professional. Go to the local running shoe place where all the runners go to get them. The guys who work there, are used to seeing all manner of problems and they are generally pretty good at helping you to get the right product. I’ve had great luck with “Superfeet.”

Using a foam roller along the side of your thigh seems to help many runners. The theory is that the IT band is over-tight and needs stretching. I have personally stretched an actual IT band and I can tell you that this anatomy is anything but stretchy. It is a tough band; it is a ligament and like all ligaments isn’t intended to stretch very much. Ligaments are not supposed to stretch much. If they did then you would have no joint stability. I don’t pretend to really know exactly why the foam roller works  – I only know that many runners report feeling better from the use of it. Add this one to your repertoire of treatments and you will increase your odds of getting better.

Use an ice pack over the affected area, Since the IT band is very near the surface, the ice has a more direct and therefore greater effect. 10 or 15 minutes is enough. If the ice pack is very cold then a shorter treatment time is better. I like to use solid ice massage over the area but you can only stand it for a few minutes, 4 to 7 minutes is enough, no longer. Use a styrofoam cup full of water and freeze it. Then peel away about 1/2 inch off the top of the cup. You can use the ice cup several times. It is a little drippy, so you’ll need a towel.

A lot of runners use Advil, Ibuprofen or Aleve. These over the counter meds can really help with the initial inflammatory phase.

Continuous running on a slanted road surface is stressful to the knee on the low side. Change direction, switch sides or better yet, find a flat surface. A short leg can have the same effect. Keep the short leg on the high side of the road and you may even equalize the stress. You might be surprised how many runners have a significantly short. A few millimeters is no big deal but anything over about 10 millimeters is probably going to cause trouble.

Poor pelvic alignment has the same effect as a short leg and causes the runner to have an uneven gait. A good chiropractor can easily fix this. Use this simple test to determine if you are out of alignment. Lie on your stomach and with your head turned to the right, then do a straight leg raise on the right, put the leg down then try the left. Repeat the test with the head turned in the opposite direction. The straight leg raise should yield level of equality with the head turned in both directions.

You can try one of those knee straps placed above the knee. I don’t like this approach, since it ignores the cause of the problem but it can be a good band aid treatment until you con strengthen your gluteal muscles. I hear many runners reporting a decrease or complete relief of pain.

By far, the best treatment is rest. Rest is a relative. In many cases you can continue to run but only up to the point that you have pain. pushing beyond that point will probably cause earlier onset and more severe symptoms. Avoid running down hills. Do not shorten your stride as this only increases the number of knee flexion cycles and irritates the knee even more.

Illiotibial band syndrome often resolves spontaneously, leaving the afflicted runner to believe that the treatment he has been using has worked.  Sometimes patients tell me that their treatment regime has worked out very well but I often wonder whether or not it would have gone away without treatment. When you have a tough schedule ahead of you, it is better to err on the side of caution and do all that you can to ameliorate the condition as soon as possible.

  1. John Burden03-07-2011

    It is a very awesome information. Thanks for sharing. St. Petersburg FL back pain

  2. Robin05-17-2013

    Thanks for the awesome article. i tried the stretches and exercises and the problem seems to be getting better! Robin

    • Dr. Steve Smith05-20-2013

      Robin,
      If you concentrate on strengthening your gluteal muscles your ITB problems will go away. Be careful when running on the side of the road and avoid sloping camber. the leg on the low side of the road is most likely to be affected with ITB. We have recently updated our You Tube with more Gluteal strengthening exercises. http://www.youtube.com/user/DrStevenSmithDC
      Steve Smith DC

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