Iliotibial band pain (ITB) is the 2nd most common cause of pain in runners and the main cause of pain on the outside of the knee. Historically it was thought that the source of the pain was tightness in the ITB causing friction over a bony prominence at the knee which became inflamed. Hence this used to be called ITB friction syndrome. Massage, foam rolling and stretching for the ITB was often prescribed. Due to more research around biomechanics, and a greater understanding of the role of the ITB in stabilising the pelvis and leg, more is known about why ITB pain occurs and how best to resolve it.
Why does it occur?
The ITB is a band of connective tissue (not muscular) attaching from the hip to the knee at the outside of the leg. At the hip the following muscles insert into it – the gluteus medius, the tensor fascia late, and the gluteus maximus. When these muscles contract they act upon the ITB to;
- reduce inward rotation of the knee,
- to reduce how much the thigh bones move in towards the midline of the body (adduction), and,
- to prevent the pelvis from sagging.
If these muscles are weak they increase the tensile stress through the ITB which can lead to increase in compression at the attachment of the ITB at the knee. Fatty structures under the ITB at the knee become inflamed and this is the pain felt by runners with ITB pain.
What research tells us on biomechanics
Research following competitive and non-competitive female runners have found that those whose who experience ITB issues compared to uninjured runners, have a which knee rotates inwards more and have a greater tendency for the leg to cross to the midline of the body (called adduction). Interestingly, this is also observed in runners who previously had an ITB issue but are now running pain free. It could be that there is a threshold in which a certain level of adduction and internal rotation is tolerated but going over this threshold leads to ITB pain.
A famous example of a runner with excessive inward rotation of the knee is Priscah Jeptoo, 2012 Olympics marathon silver medalist, and winner of the New York and London marathons in 2013. A google of her name will bring up lots of running analysis blogs on her running form. I have done a quick high level review of her running style to show you what internal rotation of the knee and excessive adduction looks like. Also take a look at the 3rd picture and contrast the leg position of the front runner to those of Priscah behind her – its sometimes easier to see when comparing to another person.
It has been found that runners with ITB pain have greater weakness in the gluteus medius muscle in the injured leg compared to the uninjured leg, and compared to non-injured runners. This is significant as the gluteus medius is one of the main muscles which prevent excessive adduction and inward rotation of the femur (thigh bone). In the stance phase in running the gluteus medius is the most active muscle in the leg and hip as it works to stabilise the pelvis and to stop it sagging to the opposite side.
Whether pronation leads to ITB issues is still being debated. Excessive pronation or rolling inwards of the ankle also causes the lower leg and knee to rotate inwards which puts additional torsion through the ITB. Some studies have found no difference in pronation between injured and uninjured runners, but a study following runners at the end of an exhaustive run found that runners with ITB pain had greater pronation at heel strike compared to controls. This may be more representative of running clients we see in the clinic who often develop ITB pain once the long runs become a feature of marathon training e.g. 18 miles, or post marathon when they start to run again after a short rest period.
Even for those who don’t heel strike when running, studies into running gait at marathon events show by the 10 mile mark the majority of runners are heel striking. This suggests that fatigue or early onset of fatigue can have an impact on biomechanics whether this is at the foot in terms of pronation, or fatigue in the hip abductors leading to increased knee internal rotation and hip adduction.
Other factors such as leg length difference can be found in runners with ITB issues. Generally when we see a leg length difference in the clinic we also find muscular imbalances around both legs, hips and the back. These imbalances need to be taken in to consideration while suggesting orthotic type interventions for the leg length difference if appropriate.
How to resolve it?
When rehabbing an ITB issue in the clinic we bear in mind a few aspects of rehab including strength, flexibility, neuromuscular training and running biomechanics. Good alignment is the foundation for optimal biomechanics and for the correction and prevention of injury so in the clinic we do a full functional assessment and then develop a tailored rehab programme around our findings.
Strengthening of the hip abductors (gluteus medius, glut minimus and TFL) has been shown to reduce ITB pain in long distance runners after 6 weeks.
We find in the clinic that weakness in the hip abductors occurs along with other muscular imbalances around the lower back and pelvis, and addressing hip abductors alone is not sufficient for good rehab of the injury. The hip abductors are one of a number of muscles that help to stabilise the lower back and pelvis and these various muscle groups should ideally work together. Imbalances in these muscle groups can occur due to posture such as sitting for 8 hours a day, crossing your knees, previous injury, aging, physical factors such as leg length difference etc. Check out the video here to see if you have gluteal weakness.
“I run, I cycle, I squat, surely I have gluteals of steel”
Not necessarily…….this is where nuerumuscular training comes in.
In neuromuscular training we teach the muscles such as the hip abductors or the transversus abdominus when to work. This may seem like an odd concept but comes about because the body adapts to the position it finds itself in most of the time. If this is sitting for commuting, at work etc, the body adapts its posture to the one of least resistance which is to shorten some muscles and lengthen others to facilitate a seated posture. The problem with this is that when you get up to run the body is still in this mindset and does not recruit sufficiently the muscles that should working away. So even if the muscles are strong, if they are not “alert” as you run then they will not be working correctly. This is where neuromuscular training comes in.
Biomechanics & Cadence
Causes of ITB pain mentioned above included a knee that rotates inwards excessively and excessive adduction at the hip. With this in mind, a study in 2011 of the effect of step rate (or cadence) on joint mechanics had some interesting findings.
When they increased the cadence of the runners by 10% above their normal cadence they found that hip adduction and internal rotation were found to decrease. They also found that there was less energy absorbed at the knee and at the hip which may have a protective effect on these joints.
Changing cadence shortens the stride while maintaining the same speed. You can check your own cadence by counting how many times your right foot hits the ground over a 60 second period while running at your usual pace. Repeat this 2-3 times and to get the average, then double this number and you get your cadence. E.g. if you found the average was 70 times (or 70bpm) your cadence would be 140 bpm, a 10% increase would 154bpm. Metronome apps downloaded to your phone can help ensure you run at the desired cadence.
I would caution that any change to your running style should be done with care. Increasing cadence and shortening your stride can lead to a change in how your foot strikes the ground and also how you use the muscles in the leg. You may notice tiredness or delayed onset muscle soreness (DOMS) in the calf for example. Start off with adjusting cadence for short periods of your run and gradually increase the duration a number of weeks. Changing it too quickly is a recipe for injury. Following a 0-5km plan at a new cadence is a good way to slowly increase cadence over a number of weeks.
So as outlined above, resolving an ITB issue has a number of considerations. Feel free to get in contact if you wish to have an ITB issue reviewed or have your leg, gluteal and core stability assessed. firstname.lastname@example.org or 01-5441225
- Ferber R, Noehren B, Hamilll J, Davis I, Competitive Female Runners with a History of Ilitiobial Band Syndrome Demonstrate Atypical Hip and Knee Kinematics. 2010; 40(2):52-58
- Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 2000;10:169-17
- Heiderscheit B, Chumanov E, Michalski M, Wille C, Ryan M. Effects of Step Rate on Joint Mechanics during Running. Med Sci Sports Exerc. 2011; 43(2):296-302