Iliotibial band syndrome… AKA IT band syndrome
For those who haven't had the misfortune of having IT band pain while running, consider yourself lucky. There aren't too many injuries that make runners stop in their tracks and sit down on the side of the road.
I speak from experience, I was three miles out, and my wife had to come to pick me up. So it was quite a humbling experience.
The catch on the outside of your knee can be spooky because it comes out of nowhere. And once you have it, it can be unsettling because you don't know what's happening.
The good news is it feels much more severe than it really is. But if it's not treated well, it can become a persistent issue.
What Is IT Band Syndrome?
So, what is it?
First, it's the most common source of pain outside the knee for runners. It's one of those injuries that can't be confused with anything else because you don't have many other muscles or relevant anatomy here.
Here's the Cleveland Clinic's definition of IT Band Syndrome:
"Iliotibial band syndrome is where a tendon called the iliotibial band gets irritated or swollen from rubbing against your hip or knee bones. It rubs against your bones when it gets too tense (tight). There are many reasons why your iliotibial band might tighten."
Soooo about this… While a widespread thought about what IT band syndrome is, this is an old-school definition. The research is starting to point us in another direction regarding what is happening with IT band syndrome. We'll get into what is causing the pain from IT band syndrome later. First, you need to understand the anatomy.
How Common is IT Band Syndrome in Runners?
About 50% of all running injuries involve the knee; of those, patellofemoral pain and iliotibial band pain comprise the overwhelming majority of runners' injuries. So even if you don't currently have IT band pain as a runner, you should be familiar with it to prevent it. [1]
When Looking at the sex distributions of running injuries of the knee, we'll notice they are a little bit different. We see patellofemoral pain more so in females, but we see iliotibial band pain more so in males. And indeed, males get patellofemoral pain, and female athletes get iliotibial band pain too. But we see them kind of switched from an injury rate standpoint.
What is the IT Band?
So let's go through the anatomy. Before we get too deep, I want to give credit to whoever named the iliotibial band. They really did a great job at keeping it simple. As its name implies, it starts at the ilium of the hip and runs down the side of the leg as a band until it attaches to the tibia.
However, the name iliotibial band can be misleading. Because, of course, things can't be simple when talking about anatomy. There are a lot more attachments than those two points.
The IT band originates from three main places on the outside of your hip:
The iliac crest - The outside ridge of your hip. It's where your hands rest when "you put your hands on your hips."
The upper part of the glute max - There are three glute muscles. The glute max is the most powerful glute muscle.
The tensor fascia latae - This muscle is short and located to the front of the side of the hip.
These origins all join, and the IT band becomes a tendon-like structure and starts to run down the side of the leg.
Once this band gets around the outside of the knee joint, it splits. One part inserts into the lateral kneecap or patella, and the other continues past the knee joint and attaches on the outside of our shin bone or tibia at a spot called "Gerdy's Tubercle."
What is the Purpose of the IT Band?
So if you've ever had iliotibial band pain or know someone struggling with it, you probably have asked yourself, or they have asked you, "Gosh, why do I even have this thing anyway? Can I just cut this darn thing out?"
Well, unfortunately, no. It's a super important structure as it provides stability to the lateral knee and, more importantly, stores energy while running.
The IT band is a very tendon-like structure. Tendons do two things:
Transmit muscle force to its insertion on a bone, aka move the joint, in this case, the hip.
Store and release energy. The IT band stores the second most energy when we run, around 5%, compared to other structures. The most is our Achilles tendon, which saves or preserves about 35% of total work when running. [2]
So cutting out the IT band wouldn't be the greatest idea. We have an IT band because it helps us with our running economy. And without it, you would run slower and for less distance.
What Causes Pain with IT Band Syndrome
Now that you understand the IT band's anatomy and role in our body, you can better understand what happens when we have IT band pain in the knee.
We used to think of iliotibial band pain as more of a friction pain; you will still see it as "IT band friction syndrome." But the evidence is starting to point out it is more likely a compression injury. [3]
There is densely innervated adipose tissue (fat) located just above your knee joint that your IT band runs overtop. Because of the high amount of nerve endings, this spot is really sensitive. So the thought is, the IT band compresses the highly innervated adipose tissue causing it to get irritated, leading to pain.
By researching the anatomy of the IT band, we are learning it doesn't flip across the femur bone (the femoral condyle) as much as we used to think. Instead, as the knee flexes and extends, the band becomes taught, compressing the structures (the fat tissue) underneath it. If the body is not accustomed to compression, it can become irritated.
Where does IT band syndrome cause pain?
Most of the pain will be localized to the outside of your knee, just above the knee joint. [4]
You can also get a referral pattern slightly farther down and in front of the knee. Sometimes the referral pain can somewhat mimic patellar tendinopathy. So make sure you're thinking about that.
What Are Some Signs I Have IT Band Syndrome?
So before I go into this, you should get any pain you are having checked out by a qualified medical professional.
However, I'm not naive to the fact we live in an age where info is a "google" search away.
So here's what you need to be looking for: [4]
A recent, very rapid increase in your training load
Your body's tissues respond and adapt to the stress you exert. It's why bodybuilders can grow huge muscles, and you can run farther and faster with training, and why rehab exercises work. Your body adapts by breaking down and building back more robust tissue. However, this process takes time. Training too much doesn't allow the recovery period to happen fully, resulting in injury.
Pain when the knee is around 25-35 degrees flexed
You are maximally stressing the IT band at approximately 25-35 degrees of knee flexion. Around this angle, the IT band also produces the highest compression forces on the structures beneath it.
Pain when pushing or compressing the outside of the knee
As we know, IT band pain comes from compression of the hypersensitive structures lying underneath the IT band. So if you manually push on these structures, it will cause pain.
Pain when going down stairs vs. going up
Going downstairs causes your IT band to perform an eccentric contraction so you can make a controlled descent. The eccentric contraction is more tension on the band. More tension on the IT band leads to more stress, and more stress will lead to pain.
Pain when taking a long step.
A long step will stretch the IT band, causing it to tighten. When it tightens, it compresses the structures underneath it, causing pain.
Pain while running downhill vs. running uphill.
When running downhill, there are higher peak braking forces. This means the IT band has to work harder to absorb energy.
What Activities Cause IT band pain?
The key to understanding what causes IT band pain is knowing its function. As we said, the IT band functions as a tendon, and tendons can be overloaded. Therefore, overloading the IT band by placing it under too much strain can lead to a potential injury.
As we talked about, one role of the IT band is to provide stability to the outside of the knee. Therefore, activities that stress the outside of the knee can lead to overstress of the IT band.
The other role the IT band has is to absorb and store energy while you run. There are certain types of running activities I will shortly get into that increase the demand for the IT band.
So when trying to figure out why you have IT band pain, you need to answer the question, "When am I loading the IT band the most?"
What types of running cause an increased load on the IT Band?
Fast running. Faster speeds increase the demands on the IT band because it has to absorb and store more energy. As a result, I often see patients develop IT band pain after starting speed training.
Running downhill. When you run downhill, your running mechanics change. Your IT band has to do a lot more work to absorb forces. Another typical time I see patients developing IT band pain is if they change their running route. I have patients change routes to involve more uphill running as uphill running decreases the stress on the IT band.
Trail running. So there is nothing wrong with trail running. But when we trail run, our stance tends to narrow. A narrow running gait causes increased compression by the IT band. So if you want to start trail running, you must transition carefully. Try to avoid pulling a hard switch. Instead, start 20% trail 80% of your previous training surface and increase your trail running by 20% each week.
Narrow running gait. As I mentioned, a narrow running gait causes increased stress on the IT band. However, trail running is not the only time your stance may be narrow. I have performed numerous running analyses on runners. One that stands out is a runner who had re-occurring IT band pain. They tried exercises, decreasing their training volume and purchasing new shoes. It turns out they were running with a narrow stance which we were able to pick up on the video analysis. The cue "pretend you are running on a track and straddle the line." helped this runner widen their stance. They have not had IT band pain since.
Slanted surface. Running on a slanted or sloped surface, i.e., on the side of a road, can cause IT band syndrome. The leg that is on the downhill side is going to be the knee that is getting excessive outside force. The slanted surface will cause the inside leg to bow, compressing that IT band.
So if you're looking for a great recipe to get IT band syndrome, run on flat ground for a couple of months, then do a hard transition to speed training downhill, on trails, or a slanted surface. [5]
What can put me at risk of developing Iliotibial Band Pain
IT band risk factors can be broken into two categories, things you can't control and things you can (training errors).
Risk Factors You Can't Control:
Male runners - Males tend to have narrower hips than their female counterparts. People with narrower hips tend to have more compression at the knee by the IT band. There is a measurement called the Q angle that measures this. A lower Q angle means more compressive forces from the IT band.
Less experienced runners - Less experienced runners tend to suffer from injuries. These injuries are often related to training errors. As people run more, they learn what works and doesn't. Experienced runners properly ramp up their training and supplement their running with proper strength training.
Training Errors:
A rapid increase in training volume - as we discussed, you need to allow your body to adapt to your runs. To do this, you need to build on the volume you are running appropriately. Running for too long or not giving your body enough rest can result in IT band syndrome.
Have a high portion of downhill running volume - you shouldn't have a high portion of your run downhill. Running downhill increases the amount of stress through your IT band.
Performing faster running workouts - when running at a higher speed, your IT band works harder, increasing compressive forces underneath it. Just like trail running, it is best if you slowly transition into speed training, do not go from 100% distance training to 100% speed training.
How to Treat IT band Syndrome
When it comes to treating IT band, you will want to follow these three steps:
Analyze your training sessions
Calm the IT band and find the root of the problem
Return to running
Analyzing your training session
The first step in treating your IT band pain is to analyze your training sessions. This will solve a majority of IT band pain problems.
Answer the questions:
Did you ramp up your training too quickly?
Does your route have a lot of downhills?
Are you constantly running on a slanted surface?
Have you recently started speed training?
Have you started trail running too quickly?
Calm down the IT band
After you have analyzed your training, you will need to decrease the irritation of the IT band. The pain you are experiencing correlates to how severe your IT band is compressing the structures underneath it. To return to running again, I recommend your average pain level be at or less than 3 out of 10.
During this time, it is important to perform rehab exercises focused on strengthening the hips and core. I beg you not to look up random exercises on the internet. Your rehab exercises need to be done progressively for maximal benefit.
Something else important to consider at this time is to have your running form analyzed. Make sure it is by someone you trust who understands the running mechanics. However, if you want to give it a try on your own, record yourself running from behind. With the recording, look at your knee window, ensuring you see space between your knees. It is a common fault in runners with IT band syndrome to let their knees collapse, which causes increased stress through the IT band.
It is okay to cross-train at this stage in your recovery, but you will want to avoid rowing, the elliptical, and cycling. All these activities cause the IT band to compress on the inflamed fat pad. Instead, I recommend swimming or even walking on a level surface.
Return to Running after IT band syndrome
Congratulations, you are on the final stretch if you have made it this far. That being said, this is also the most challenging part of your recovery.
With your pain under control, you will want to start running at your regular volume again.
DO NOT DO THIS.
You need to start slow to allow your body to adapt to running again. To do this use the interval running pattern below.
Total time for all workouts: 30 minutes
Day 1: Run 1 min | Walk 1 min
Day 2: Rest
Day 3: Run 3 min | Walk 1 min
Day 4: Rest
Day 5: Rest
Day 6: Run 6 min | Walk 1 min
Day 7: Rest
Day 8: Run 9 min | Walk 1 min
Day 9: Rest
Day 10: Rest
Day 11: Run 12 min | Walk 1 min
Day 12: Rest
Day 13: Run 15 min | Walk 1 min
**If you have any increase in pain during or after your run, rest for two days and move back a day.
Treatment Options that Will NOT Help Your IT Band
Because the research has what we now know is causing IT band syndrome (compression of the fat pad beneath the IT band versus friction over the lateral femoral condyle), many old-school treatment techniques no longer make sense and will not work. I want you to be aware of them.
Stretching the IT band
Some runners worry about not stretching, but it doesn't reduce your risk of developing IT band pain. More research is coming out suggesting the IT band does not stretch. [6]
That being said, I want to clarify the difference between stretching and a dynamic warm-up. Stretching is your classic hold for 30 seconds for three sets of a hamstring stretch. A dynamic warm-up can include some stretching but, more importantly, gets the heart rate up and excites the muscles and nervous system. A dynamic warm-up routine before a run can be beneficial. Think of it as priming an engine.
Foam rolling/Massaging the IT band
I know foam rolling is popular in the running community, and I may catch some slack for putting this here, but let me explain why it doesn't help your IT band pain.
The goal of foam rolling is to "mobilize the tissue, increasing the pliability and elasticity." This was thought to help IT band pain because it made the IT band more elastic so it would not rub over the lateral femoral condyle.
While some runners have reported relief from their IT band pain because they are overstimulating the nerves that perceive pain in the IT band when the nerves are overstimulated, it makes it, so the pain does not seem so bad. [7]
If you have ever played baseball, it is like swinging a weighted bat. Swinging a weighted bat will make your normal bat feel light, allowing you to swing faster. With foam rolling, you put yourself in a lot of pain, so your normal pain is not as bad.
Summary:
So there you have it. IT band syndrome is common and can be a debilitating injury for runners. With new research, we have changed our thinking about what is causing IT band pain. We have become much better at treating IT band pain with this new understanding.
