Ouch! My Knee Hurts | IT Band Syndrome

Guest Blog: Kevin Sherman

• What is the IT band?
• What causes IT band syndrome?  
• How can we fix or prevent it?

The most common cause of lateral knee pain in runners is Iliotibial Band Syndrome. “IT band syndrome”, or “ITBS”, most often presents as pain over the lateral knee which appears during or after running.  The pain often subsides immediately or within a few hours after running, but returns with every run.  

The IT Band

Anatomically, the IT band is a long, thick structure running along the lateral portion of the thigh, from the hip to just below the knee.  It essentially acts as a long tendon of the gluteal muscles involved in moving the thigh out and back (hip abduction and extension).  Structurally, the IT band is extremely dense.   It is more akin to a leather belt than a spring.  Like a tendon, it has very little give, and for all practical purposes, it does not stretch.   One can place a stretch on it, but that does not mean it will give.  For eons, athletes with ITBS have tried to statically stretch the IT band with little, if any, lasting effects.  Treating symptoms rather than causes has little value when dealing with this syndrome.  

IT Band Syndrome

In runners, abnormal tension develops within the IT band due to WEAKNESS OF THE HIP ABDUCTORS (GLUTEAL MUSCLES).  That’s right, your knee pain is rooted your buttock, not your knee.  If the gluteal muscles are not strong enough or are not firing properly, the knee will drift inward after footstrike, placing additional stress on the IT band.  The resulting compression of the soft-tissues over the lateral knee eventually leads to inflammation, myofascial adhesions, scar-tissue and pain, otherwise known as Iliotibial Band Syndrome.

IT band syndrome is no longer considered a friction syndrome, as it once was.  It appears to be more of a compression syndrome in which the IT band repeatedly compresses and irritates the soft-tissues over the lateral side of the knee and thigh.

Research has shed much light on gluteal weakness as one of the primary causes of ITBS.  In 2000, a pivotal  study was done by Michael Frederickson, MD, and his colleagues at the Stanford Department of Functional Restoration 1.  In the study, athletes with IT band syndrome had significantly weaker hip abductors than their uninjured counterparts.   After completing a strengthening program targeting the hip abductors, the injured runners showed significant improvement in their symptoms.  Symptom improvement paralleled the improvement in hip abductor strength, in fact.   The program also included static stretching; however, the therapeutic benefit of static stretching has been called into question and is currently under significant clinical and scientific scrutiny (perhaps the subject of a future post).

This is somewhat consistent with what we see clinically; Athletes with IT band syndrome almost always display a relative weakness of the hip abductors.  Strengthening the gluteal muscles and treating the soft-tissue fallout generally results in a functional cure.  Treating the weakness or the soft-tissues alone only provides short-term relief. Both problems must be addressed in order to effect lasting change.

Clinically speaking, along with exercise, soft-tissue therapies designed to flush edema and break up scar and adhesions, (e.g., Active Release Techniques, Graston Technique, etc.) are very effective.

Besides gluteal weakness, there are certain activities that can cause acute IT band syndrome:

• Too much volume or distance, too soon (overtraining).
• Running downhill.
• Running on cambered roads.
• Extreme muscle development of the quadriceps (muscle bulk adds to the compression of soft-tissues sandwiched between the muscle and the IT band).

Prevention

Common self-employed techniques for treating and preventing ITBS include regular use of the foam roller over the quadriceps, IT band and gluteal muscles, dynamic (not static) stretching of the gluteal muscles and strengthening exercises involving the gluteal muscles involved in hip abduction.  See below for a few of the exercises you can try on your own.

Controlled lunges

 Do this in front of a full length mirror.  Look straight ahead, with an upright posture. Lunge forward in a slow, controlled fashion.  THERE SHOULD BE NO INWARD DEVIATION OF YOUR LUNGING SIDE KNEE.  If there is any deviation, faltering, bobbing or loss of balance, then you have gone too far.  Only work within the range where you can perform the lunge without inward deviation of the knee.  Slowly build depth over successive workouts.  It takes most people about three weeks before they can do a rock solid lunge without the knee faltering.  Practice at least four times per week for three sets of ten lunges.  

Gorilla walks

Forward/Backward Gorilla Walks:

Using a piece of resistance band around the ankles:  Start with the feet together.  Keeping the knees slightly bent, step forward and away from the midline. Next, bring your feet back together by moving the opposite foot.  Alternate feet and make ten steps going forward, then ten steps backwards.   Do two sets of ten steps.

Side-to-Side Gorilla Walks:  Using a piece of resistance band around the ankles:  Start with the feet together. Keep the knees slightly bent.  Move one foot to the side, approximately 18 inches.  Using the opposite foot, bring the feet back together.  Do not drag the foot on the floor.  Use your hip muscles to control the motion.  Repeat.  Do two sets of ten steps to the right and ten steps to the left.

Standing abductions

Using a piece of resistance band around the ankles:  Start with the feet together.  Move one foot back and out, approximately 18 inches.  Bring the feet back together. Repeat.  Two sets of 10 repetitions on each side.  

The disclaimer:  Lateral knee pain should always be evaluated by a physician.  Many other knee problems can mimic ITBS, including injuries to the lateral meniscus, lateral collateral ligament, tumors, infections and cysts.  Further, hip abductor weakness can cause numerous other injuries that may need to be evaluated.  Consult with your physician before embarking on any exercise program.

ITBS is a common condition.  Many of its effects can be prevented or diminished by focused strengthening of the gluteal/hip muscles.  Hip stabilization exercise should be a regular part of every athlete’s training.

Reference:

1. Fredericson, M. et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clinical Journal of Sport Medicine 08/2000; 10(3):169-75