Art of Prevention
Our mission is to decrease the prevalence of preventable injuries and athletes therein optimizing performance by decreasing the time that our athletes spend benched due to injury. We are going to distill information and practices from experts in the field of injury prevention. High level coaches and top performing athletes. We believe this information should be accessible to everyone so that we can reduce the rates of preventable injuries.
Art of Prevention
Iliotibial Band Syndrome: Prevent, Recover, Perform
Navigating the relentless discomfort of iliotibial band syndrome (ITBS) was a defining chapter of my running career at Adams State University, one filled with not only pain but profound lessons. My personal saga unfolds in this episode, where I recall the trials of ITBS, the crushing impact it had on my performance, and the invaluable insights gained on the road to recovery. We move beyond the outdated notions of ITBS as a mere friction issue, exploring the advanced understanding that frames it as a complex interplay of compression and tension within the body's anatomy.
As we dissect the intricate dance of the IT band with the knee, you'll gain a newfound appreciation for the vital roles played by strength training, proper biomechanics, and training load management. I share the transformative power of embracing a multifaceted strategy that marries progressive overload with targeted exercises for the hip abductors, extensors, and flexors. This comprehensive approach not only addresses ITBS but also fortifies the body against future afflictions, honing in on the synergy between recovery, strength, and technique that can elevate an athlete's resilience and performance to unprecedented heights. Join me for this deep dive into the world of ITBS, where pain meets purpose, and discover how to turn your greatest setbacks into your most triumphant comebacks.
Resources:
Hutchinson, L. A., G. A. Lichtwark, R. W. Willy, and L. A. Kelly. 2022. “The Iliotibial Band: A Complex Structure with Versatile Functions.” Sports Medicine 52 (5): 995–1008.
Mucha, Matthew D., Wade Caldwell, Emily L. Schlueter, Carly Walters, and Amy Hassen. 2017. “Hip Abductor Strength and Lower Extremity Running Related Injury in Distance Runners: A Systematic Review.” Journal of Science and Medicine in Sport / Sports Medicine Australia 20 (4): 349–55.
Fredericson, M., C. L. Cookingham, A. M. Chaudhari, B. C. Dowdell, N. Oestreicher, and S. A. Sahrmann. 2000. “Hip Abductor Weakness in Distance Runners with Iliotibial Band Syndrome.” Clinical Journal of Sport Medicine: Official Journal of the Canadian Academy of Sport Medicine 10 (3): 169–75.
Fairclough, John, Koji Hayashi, Hechmi Toumi, Kathleen Lyons, Graeme Bydder, Nicola Phillips, Thomas M. Best, and Mike Benjamin. 2007. “Is Iliotibial Band Syndrome Really a Friction Syndrome?” Journal of Science and Medicine in Sport / Sports Medicine Australia 10 (2): 74–76; discussion 77–78.
IT Band Syndrome article by RIch Willy PT PhD
https://www.physio-network.com/blog/iliotibial-band-pain-in-the-runner-part-1-etiology-and-assessment/
If you have listened to this podcast for any length of time you know that strength training is crucial for runners. However a major obstacle for many runners is not know what to do once they get to the weight room. This PDF seeks to change that. It will arm you with the tools you need to effectively strength train to get the most out of your runs.
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Hello everyone and welcome to yet another episode of the Art of Prevention podcast, and today I will be performing a solo episode. That is, on a topic that is very near and dear to my knees, and this topic is iliotibial band syndrome. So IT band syndrome, or ITBS, is what we're going to be discussing today, and I actually have a decent amount of knowledge about IT band syndrome because when I was a runner at Adams State University, this is one of the things that put me out for basically two to three months. So I have my personal experience with IT band syndrome and I also have a lot of reading that I've done recently so that I can better treat patients with IT band syndrome. Now today we're going to be talking about some of the factors that are associated with iliotibial band syndrome, some of the treatments that I got, as well as some of my story that I had with IT band syndrome. So my story with iliotibial band syndrome I mean, this was probably 10 or 11 years ago, so I may be a little bit foggy on some of the details, but I was in my second or third year as a collegiate runner and I just had this insidious onset of pain on the outside of my knee and this is truly the bane of many runners existence. So the biggest cause of pain on the outside of the knee for runners would be this IT band syndrome or iliotibial band syndrome. It can affect up to 12%. Some studies indicate like 10 to 16%, so around that 12% mark, and it can be debilitating to the point where that person is unable to run for a short period of time. It can be a chronic injury and it can be an issue that comes back over time and honestly, it can be a career ender for many a runner and we're going to talk about some of the reasons as far as why it can be a career ender, some of the misunderstandings behind that.
Speaker 1:But my story was I was increasing my mileage and I probably wasn't doing the right things from a recovery standpoint to handle the loads that I was placing on my legs standpoint, to handle the loads that I was placing on my legs. So when I was in undergrad I was terrible with sleep. I was probably not doing the right things nutrition wise as far as getting in enough protein and macronutrients to handle these stressors and loads that I was putting my body through. And then mental stress and all these things also were massive contributing factors. So by me going over this injury and some of the causative factors like by no means am I blaming my training loads necessarily, or blaming coaching or anything like that it's really, if I think about who's responsible for this, I put it on myself because I wasn't doing my due diligence in recovering appropriately from these high loads.
Speaker 1:So how this began with me was insidiously, which is how most of these overuse injuries occur. So I just started having a little bit of a dull ache on the outside of my knee and then this dull ache progressively worsened, especially as I bullheadedly just ran through all of these workouts and hill runs and things like that. Actually we did mountain runs, so we were running actually in the mountains at 9,000 feet and specifically the actions and types of running that will significantly affect structures like the iliotibial band include downhill running. Now, luckily for us, we would have our coach basically drop us off at the base of a mountain and then we would just run uphill for long periods of time. But in some instances we would do a turnaround and then we would go and we would run downhill for 20 to 30 minutes at a time and, like I said, this is more of me not recovering appropriately, as opposed to any kind of training load error that was imparted from the coaching staff or anything like that. So it began insidiously and I started getting treatment in the training room and about nine or 10 years ago a lot of our thinking was very different about IT band syndrome than it is now and the treatments that we thought would be really beneficial were really different from what they are now. So we were doing a lot of scraping and a lot of deep tissue massage and needling at the site of pain in my knee. So right on the outside of my knee, we would scrape it until it was bruised and you know, then I would try and run as far as I could without it hurting and basically, if you're searching for pain, you're probably going to find it on that run at some point. So I would basically run as far as I could until my knee hurt, until I couldn't run anymore, and then I would stop, which is also not a very good way to come back from an injury and not a good way to appropriately reload with running and some of the other things that I could have been doing really just wasn't doing because we didn't really have the knowledge necessary to implement these more beneficial treatment practices that I may discuss a little bit later.
Speaker 1:So what is the IT band? The iliotibial band is a very dense piece of connective tissue that extends down the length of the outside of the thigh from muscles that are more proximal in the hip, so those two muscles that it connects to include the TFL, the tensor fasciae latae and the upper fibers of the gluteus maximus, so the superior fibers of the glute max, so actually part of your glute max connects to the IT band. And then the other portion, the more inferior fibers of your glute max, attach to the linea aspera, or this little line that's on the back and the outside of your femur. So both of these muscles, one on the outside in front of your hip and the other one in the outside and back of your hip, combine to form this very dense piece of connective tissue that runs down the outside of your thigh. And if you watch the knee move from flexion and extension, so if you just move that hinge joint of the knee, you can actually see different portions of that IT band turn on and turn off. You could say so tension and detension.
Speaker 1:The tissue itself isn't necessarily contractile, but it's the musculature up the chain that is contractile, and this is one of the reasons that many of the previously proposed mechanisms and treatments, as far as like mechanisms to improve, we didn't find to be very effective. So things like trying to stretch the iliotibial band I mean that's like trying to really stretch out like a tendon, and we know that the iliotibial band can take a lot of stretch and a lot of pull without actually changing any of its characteristics whatsoever and then things like foam rolling will induce a transient improvement in our range of motion. However, if someone is thinking about foam rolling for the iliotibial band or foam rolling for an IT band syndrome, the things that we actually want to foam roll would be more proximal or more up the chain, in areas like the hips. So foam rolling those muscles like the glutes and the TFL would be far more effective. But remember that effectiveness is short term in duration. So can this be beneficial? Well, if you love foam rolling, I'm not going to tell you to stop foam rolling. Just know that a lot of those improvements are going to be short-term. Now, what's wrong with short-term improvements? Absolutely nothing. So if we want to get a short-term improvement in the range of motion and decrease some of the tension in the IT band, then, yes, foam rolling can be very effective in doing that, but we also have to utilize things that we found to be more effective, such as strengthening of the muscles on the outside of the hip, including the glutes and the TFL, but also the posterior lateral muscles and the AB ductors, such as the gluteus medius, the gluteus minimus and some of the deep external rotators of the hips. But I'm getting ahead of myself.
Speaker 1:Previously we attributed many of the pain and discomfort of IT band syndrome to a friction that is applied to the outside of the furthest away portion of the femur when our knee is moving from flexion and extend to extension or extension to flexion, so as we're straightening and bending the knee, we would look at that IT band and cadaver models and things like that and we would see what looked like a sliding of the iliotibial band over this lateral femoral condyle iliotibial band over this lateral femoral condyle. But this was actually more of an optical illusion because of the tensioning and detensioning of the front portion of that IT band and the back portion of that IT band, as different muscles were actively pulling on that iliotibial band when we moved and bent that knee. So it was actually more of an optical and visual illusion that that band was sliding back and forth. And the reason that we know this? Because now more detailed anatomical depictions and more detailed anatomical dissections of the knee have found that there are many locations that the iliotibial band connects to in the outside of the knee. The most prominent connection is to what's called Gertie's tubercle. So Gertie's tubercle is actually on the tibia. So if everyone's thinking, oh, it just attaches to the outside of your tibia, which is distal to the knee, then that sliding obviously can occur as we bend and straighten the knee. However, there are other accessory connections as well, and there are connections through that iliotibial band that permeate the outside of the thigh into some of the quadriceps and hamstring muscles. So we actually do have dense fibrous connections that connect that IT band to the outside of the femur as well. So if we have connections to the femur, we're probably not going to be sliding up and down on that femur. So this decreases the likelihood of friction being an etiological or causative factor behind IT band syndrome. Now, one thing that we do have as we're running and going through the gait cycle of walking as well, is we have compression of that IT band against that lateral femoral condyle as well as some of the densely innervated tissue that's in between that outer portion and distal portion of the IT band and the connective tissue on the outside of the knee.
Speaker 1:So a lot of the treatments that I was doing was a lot of the treatments that I was receiving were more likely to irritate this dense band of connective tissue and the highly innervated tissue underneath. Now, could those things induce some analgesia or pain relief in the short term? Yes, of course. However, I probably wasn't the best candidate for those types of treatments, such as the soft tissue direct treatment to that IT band. So I was doing more of irritating that from a treatment standpoint.
Speaker 1:And then one of the causative factors was a training load error, mostly because I wasn't very good at recovering. But the training load error for my comeback at first was also not appropriate for healing my IT band and decreasing the sensitivity of that IT band, because I would basically just go out and run as far as I could until my knee hurt again and then I would limp back to the training room and ask them why is this not getting better? And the thing that I had to do. The one of the most painful things that a runner ever has to do is do an extraordinarily slow progression back to running, and this slow progression includes increasing by one minute a day, getting really small victories at first, with maybe just 10 minutes of running without pain, and then taking the next entire day off and then the next time I go out to run, running for 11 minutes, and this is a painstaking way to get back into running normal volumes, but this was effective for me.
Speaker 1:So oftentimes that training load error can one cause an IT band syndrome, but it is also something that can prolong this IT band syndrome, also for irritating the IT band with things like cycling and running or obviously running, cycling and things like the Stairmaster or other cross-training techniques, then that's also going to prolong recovery. So cross-training is a great tool to stay aerobically fit while recovering from something like iliotibial band syndrome. However, a word of caution would be does your knee feel worse after cycling or after running? There are modifications that you can make to the bike and, honestly, the StairMaster is probably not the best idea while coming back from IT band syndrome. But there are other cross-training techniques like pool running or swimming or anything of that sort that can help maintain aerobic fitness but not induce irritation in that iliotibial band.
Speaker 1:Now I would say one of the things that I could have done a better job of when I was an athlete back in the day is actually strength training. So if we think about this dense, long, broad piece of connective tissue that is the iliotibial band, it actually acts very much like a long, thin tendon and when we look at some of the pathology associated with IT band syndrome, we'll actually induce thickening of this IT band in its more distal segment, which is very similar to what happens when we do have a tendinopathy. We'll have a thick, inflamed and swollen tendon. This is another reason why we thought it was a friction etiology is because it would get thick, inflamed and swollen. However, what's truly occurring is more of a compression on some of those dense connective tissues that are highly innervated, like I discussed earlier, and compression of the tendon itself. And this compression etiology can sometimes be due to factors such as our running biomechanics.
Speaker 1:So if the knee and the leg is internally rotated too much while running, or if that knee is adducted too much while running, this can induce a little bit more stretch and compressive force on the outside of the knee that can, with a training load error, become painful. A lot of times people will talk about this as a quote unquote crossover gait style. So if you're looking at somebody running from the front and they're running on in the middle of the road with nice, a nice white line down the middle of that road and they're running and their foot is crossing over the midline, that would be a quote unquote crossover gait pattern and this would add a little bit more biomechanical force at the outside of the knee. Now some people are able to do that and not have any knee pain whatsoever, and that's because they're not having these training load errors in the hip abductor, so the musculature on the outside of the hip. Now the thing that's tricky about this is that there's not a high predictive value for weakness in the hip abductors.
Speaker 1:In relation to, specifically, it band syndrome, some authors say yes, it does have a predictive value. Some authors say, no, it does not have a predictive value. Some authors say, you know, hip abductor weakness can be predictive for numerous injuries to the lower extremity, but we can't necessarily pinpoint what's going to be the injured segment on you particularly. So my thinking here is okay. We know that people with IT band syndrome and there is a lot of literature that shows that people with IT band syndrome have weakness in the hip abductors, so that gluteus medius, gluteus minimus, et cetera, and part of a good structured programming to get back to running would be strengthening of those hip abductors. Back to running would be strengthening of those hip abductors. So it may not be causative of the IT band syndrome and many authors actually postulate and theorize that IT band syndrome will inhibit the musculature on the outside of the hip and the musculature on the outside of the glutes, those hip abductors.
Speaker 1:So this really turns into a chicken or egg philosophical argument and really this argument is more for the researchers than us people trying to prevent injuries as well as treat injuries. So in my opinion, there's nothing wrong with getting strong, there is nothing wrong with having the utmost capacity and strength and activation of motor units in the outside of the hip. So for me, whenever I have a runner in the office, I'm always trying to push them towards things like strength training, to the extent where I've actually created a very inexpensive resource for runners that want generic and broad programming for strength training of their lower extremity. In strength training or with strength training we can increase motor unit activation, we can improve capacity of the connective tissues at the knee and the hip, we can improve coordination, we can improve running economy all these wonderful things. So, whether weakness in the hip abductors causes IT band syndrome or not, this is a mute point because at the end of the day, we know things like strength training can potentially be protective but can also improve performance in things like running. And I've had a couple of people go through the strength training PDF and they've said all of them wonderful things about the programming that hill workouts are becoming easier, that running is becoming easier, the running economy is going up.
Speaker 1:But that is beyond the scope of this podcast, specifically because we're really just talking about the IT band, right? So sorry about that tangent. I always go on these long tangents and things. So thank you for sticking with me if you're still in this portion of the podcast. So we know that this is more of a compressive etiology and things that can flare up. This compression etiology actually include things like downhill running. So many individuals, if they were to run downhill, they would have a flare up of their IT band syndrome. They would have a flare up of their IT band syndrome. However, if we flip that and did the inverse of that and actually ran or walked at a brisk pace uphill, we could instill some aerobic stimulus and some stimulus to the tissues but not place as much stress at the knee. So in many of my runners, when they're coming back from really just knee injuries in general, we may have them run on an uphill treadmill or running only on an uphill slope, and this decreases the amount of force and strain on the knee, including the front of the knee, but in question today is the outside of the knee, and this can be a way in which we can slowly, progressively go back into running without those training load errors.
Speaker 1:So now let's move on to the causative or etiological factors which, honestly, I've been talking about this whole time. The factors. The number one factor includes a training load error. So too much, too soon, too much intensity coupled with too much volume. There are a couple of different ways in which we can describe this. The training load error is basically the number one thing, and this could also be akin to what I was discussing earlier a recovery error where me, I wasn't recovering appropriately, and that's why my soapboxes athletes need to be getting sleep. They need to be getting adequate amounts of macronutrients, specifically protein, especially if that individual is growing. And the secondary issues. The issues secondary to those training load errors would include things like running biomechanics, those internal rotations of the knee or too much adduction or crossover gait pattern, et cetera, while an individual is running, and then I would say, lastly, we would look at the strength of the hip abductors.
Speaker 1:Now we obviously want to look out for training load errors too much, too soon. I like Tim Gabbitt's work here as far as monitoring chronic and acute workload ratios, which factors in intensity, as well as some of the factors like qualitative measures, such as how did you feel, how intense did that session feel today? But we also need to be looking at our cumulative stressors and that includes our psychological stressors. So are we going through a big move? Are we going through issues with our spouse or significant other? All these things can contribute to our overall cumulative stress and there really shouldn't be a big differentiator between psychological stress and physiological stress, because all of this is under the umbrella of stress and stress itself can attribute to and contribute to overall stress on the body, so it can make us more susceptible to these musculoskeletal injuries. So don't sleep on stress. Overall stress can contribute to these training load errors.
Speaker 1:Now, when we're talking about treatment of the iliotibial band, we obviously don't want to instigate another training load error. So we have to slowly return to running and in the meantime, we actually have a golden window of opportunity where we have so much energy and so much capacity which we can convert to strength training. So I already talked way too much about the strength training PDF to strength training. So I already talked way too much about the strength training PDF. But specifically, when we're talking about strength training of the iliotibial band and the musculature that connects to that iliotibial band, we're talking the hip abductors as well as the hip extensors and hip flexors, and honestly, I would think of strengthening in that order. So I would begin with strengthening of the hip abductors this also shouldn't put too much stress on the outside of the knee itself when done appropriately Then working on the hip extensors, such as the gluteus maximus and the hamstrings, and then, last but not least, working on the hip flexors, such as the rectus femoris and the tensor fasciae latae and the quadricep muscles as well. Really, a well-rounded strength training program would be the most appropriate for these people or for individuals returning from iliotibial band syndrome. So it's a good idea to strengthen not only at the hip but including areas like the core and the lower extremity.
Speaker 1:And something that I found out when I was running back in the day was when I was injured. I had a heck of a lot of time. So me, I always looked at injuries as an opportunity to improve my form, improve my technique, et cetera, and that was through mobility exercises, strengthening exercises. And one thing if I could get into a time machine and go back and talk to Nick of undergrad is, I would say, increase the load, decrease the volume with my strengthening exercises. So I would be doing a lower rep scheme with my exercises but be doing things more in the gym as opposed to in the training room with two pound dumbbells and stuff like that. So me, I was that classic runner trying to get stronger by using a 15 pound of resistance band around my knees, doing clamshell exercises and doing things like you know, carrying a one pound medicine ball or two or five pound medicine ball and doing things like bird dippers, and these are all good and fine and things like that.
Speaker 1:However, our connective tissues really need a lot more load to change their capacity and if we're able to induce that load and capacity changes, or and those capacity changes without irritating the tendon, then we're going to be much better off once we are able to return back to running. So there were things that I was doing in my treatment as far as training, load errors with my return to running, as well as things that I could have been doing better, such as strength training more appropriately, strength training for strength as opposed to trying to strength train for muscular endurance, and things like that. So, as far as treatment is concerned, a progressive overload is the number one thing that we need to do and we need to progressively overload appropriately, starting with things like strength training and then increasing the velocity of our training as we go and then finishing up with plyometric training and strength training with force and speed. Thank you all so much for listening to this episode and to wrap up here, I'm going to go over some of the main points. So IT band syndrome, the bane of many runners, existence right, the most common cause of runner's pain on the outside of the knee.
Speaker 1:Cause of runner's pain on the outside of the knee. It's not really associated with friction along the knee, but more associated with compression and it acts a little bit more like a tendon that needs progressive overload in order to return us back to our activities. Now, when we're talking about the causative factors, the number one cause would be that training load error or, like in my case, an inadequate recovery error. So make sure that you're getting enough sleep, make sure that you're getting enough macronutrients that includes protein, but also those other macronutrients like carbohydrates, fats and water. Make sure that you're hydrating appropriately and, lastly, you know running biomechanics and the strength of the hip abductors.
Speaker 1:I think every runner should be doing things to strengthen the hip abductors, regardless of if they're worried about an injury or not, or if they have something like IT band syndrome. We know from multiple studies that hip abductor weakness whether that's caused by an injury or is just something that occurs over time due to a lack of strengthening we know that this is associated with running injuries. So everyone should be strengthening those hip abductors. And maybe one day I'm going to go down my tangent and rabbit hole on why no man should do clams. No man or woman should do clams, because clamshell exercises they're probably the most prescribed for hip abductor strengthening but is probably the least effective exercise. And if you look at studies, it is the least effective exercise for hip abductor strengthening. So if you are interested in better hip abduction strengthening, then check out that strength training PDF or send me a message on Instagram or through email and maybe I'll do an entire episode on hip abductor strengthening for runners and for lifters, et cetera.
Speaker 1:If you are a runner and you are recovering from IT band syndrome, make sure that one the treatments that you're doing are not irritating that tendon on the outside of the knee. So make sure that you know treatments that you're doing are not irritating that tendon on the outside of the knee. So make sure that you're not scraping that tendon itself, because that's probably going to lead to more irritation over time. Make sure that you are also not irritating the injury with your training. So make sure that your progressive overload training, whether that be strength training or running or plyometrics is not irritating the outside of the knee. So you want to start with small victories and then build on those small victories to get back to normal running and training.
Speaker 1:Very last but not least, I do want to give a shout out to a researcher who has done a ton of work in the realm of the iliotibial band, and that researcher is Richard Willey up at Montana Running Lab, so you can follow them on Montana Running Lab. A lot of the information that I've got that I use to treat patients, as well as a ton of the information that I got to make this recording, is from his work Some of his research work, some of the articles that he's written and some of the other podcasts that he's been on. I sent them an email and asked them if they would be willing to be on the podcast and those people are busy people. They're actually developing running courses themselves. So if you have a chance, I would highly recommend a course with Rich Willie and I would highly recommend you go on, rich Willey, and I would highly recommend you go on and learn more about some of the great work that they're doing up at Montana Running Lab.
Speaker 1:Thank you again for listening to this solo episode. If you have any feedback or anything like that for me regarding topics or structure to these podcasts, be sure to shoot me a direct message on Instagram or send me an email on things that you all would like to hear about. Thank you so much for listening today and thank you for your interest in injury prevention. I hope that you enjoyed this episode of the Art of Prevention podcast. If you did enjoy and or benefit from some of the information in this podcast, please be sure to like, subscribe and share this podcast, or please give us a 5-star review on any platform that you find podcasts. One thing to note that this podcast is for education and entertainment purposes. Only entertainment purposes only. No patient is formed and if you are having any difficulty, pain, discomfort, etc. With any of the movements or ideas described within this podcast, please seek the help of a qualified and board-certified medical professional, such as your medical doctor or a sports chiropractor, physical therapist, etc.