Iliotibial band syndrome: the runner's road to recovery

In a recent article, which you can read here,  musculoskeletal specialist Pat Gilham explored the characteristics and risk factors of iliotibial band (ITB) syndrome – an injury that leads to pain in the lateral region of the knee in runners and cyclists. In this article, Pat explains the best treatment options for ITB syndrome, and reassures athletes that they can be pain free!

If you suffer or have suffered from ITB syndrome, the burning question is how to best treat ITBPS? Here are some ideas based on research-validated evidence:

*Target the tensor fasciae latae (TFL) and gluteus maximus (GMx) muscles

Because the TFL and GMx muscles play a large role on the tensioning component of the ITB, treatment should be focused on reducing the tension of these large muscles. This can be done at home using a foam roller or trigger point ball (see figures 1a and 1b below), or to have massage therapy or dry needling by a clinician to target myofascial trigger points⁽¹⁾.

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Figure 1a: Targeting the TFL muscle

Rolling TFL: To target the TFL muscle, find the soft belly of the muscle between the bony part of your hip and your pelvis. Place the roller in this area and lie on it using your hands and opposite foot to take some weight. The target leg should be relaxed on the floor. Massage here by foam rolling for 1-2 minutes.

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Figure 1b: Targeting the GMx muscle

This exercise is very similar, but you just target your bum cheek on the roller rather than your hip. If this is too sore, use a softer roller.

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*Check ankle flexibility

If the ankle is stiff in straight-line movements, it can make the knee drift inwards when landing. This can make the TFL and GMx muscles work harder, increasing their tone, which then causes more pressure on the outside of the knee. This stiffness can be caused by low flexibility at the ankle joint itself, or increased tone to the calf muscle complex. Have a go with the two exercises shown in figures 2a and 2b to cover both scenarios.

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Figure 2a: Right ankle joint stretch

Hold for 1-2 minutes.

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Figure 2b: Using a medicine ball to massage your calf

Massage for 1-2 minutes.

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 *Strengthening your hip

Hip strength has been proposed as very significant when resolving ITBPS in runners^(1-3,5,6). The hip needs to be robust enough to support the knee when absorbing the impact of running. If the large muscles of the hip don’t adequately support the knee, more stress can be placed on the ITB. A great exercise to add to your strengthening routine is a single leg squat off a box or step (see figure 3). This mimics the landing mechanism of running and can be varied to make it easier or harder to control. If performed correctly, you should feel your buttock muscles work!

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Figure 3: single leg squats off a box

Try to imagine sitting on a chair so your hips hinge backwards. Your weight should feel slightly more into the heel. Try to keep your knee from going past your toes. Keep the movement shallow, the depth is not important. If you’re having trouble with balance, hold on to something whilst you familiarise yourself with the technique. Continue until your bum muscle is fatigued and repeat for three sets.

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*Strengthen your calf

The calf muscle has to endure vertical forces of eight times bodyweight when landing during running. Have a go with these two variations of calf-strengthening exercises shown in figures 4 and 5. The first exercise will need to be done in a gym environment using the knee extension machine and step or a ‘donkey calf raise’ machine.

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Figure 4: Seated donkey calf raises

Use a knee extension machine to strengthen the calf. Sit on the edge of the seat and place the pad (normally placed on the shin) on your knee. The weight should now be vertically down through your foot. Place your fore-foot on a step and lift the weight by raising your heel. Slowly lower and repeat 30 times for four sets. Perform one leg at a time.

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Figure 5: Standing single leg heel raise

This targets a difference muscle of the calf complex. It’s the same technique, but just done in standing with a straight knee. Keep the repetitions slow and controlled. Aim for 20-30 repetitions and repeat 4 sets.

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*Local treatments

Applying ice to the area for 10-15minutes can give some relief, and should help with reducing inflammation to the irritable fatty tissue of the knee⁽³⁾. Oral non-steroidal anti-inflammatory medication (NSAIDs – eg Ibuprofen, Diclofenac etc) can also have the same effect but a pharmacist or doctor should always be consulted beforehand because they can have side effects. Taping the area can give some runners short term relief and is more comfortable using flexible tape.

If the pain is very acute, or if there is little time before a running event, an ultrasound-guided corticosteroid injection can be applied by an appropriately qualified clinician (eg a sportsphysician) to the irritable fatty tissue above Gerdy’s tubercle. This would ideally be completed in combination with continued rehabilitation to alter biomechanical faults which may be causing the symptoms.

*Alter your running technique

In combination with a structured strengthening and flexibility program as indicated above, having a professional review your running technique is very important for long-term recovery. Using video technology is very beneficial for both the clinician and you, the runner. Here are a few common techniques to use to avoid ITBPS: 

How to avoid too much knee bend on landing:

The best way to avoid excessive knee bend when landing is to prevent over-striding as well as trying to reduce contact time with the ground. This can be done by increasing your step rate⁽⁵⁾. Once you’ve worked out your step rate, it is recommended to gradually increase this by 5-10% every run, ideally working towards 180 steps per minute. Using a metronome on your phone or music for keeping the beat is the easiest way to maintain you step rate consistently. 

How to avoid crossover landing:

The best visual cues to prevent crossing over your feet too much when landing is to imagine running on the outside of a straight line or trying to place your feet under your hips rather than under your belly button (see figure 6)⁽⁵⁾.

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Figure 6: Avoiding ‘crossover landing’

The right foot is drifting to the centre and landing under the belly button. It should instead be landing under the right hip.

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How to stop the opposite hip dropping

This can be a sign of poor activation in the buttock muscles on the landing hip, and the trunk muscles of the opposite hip/ trunk. For this reason, strengthening exercises, as demonstrated above, should be done in combination with verbal cueing whilst running. The best verbal cues a runner can use is think about keeping the pelvis high when landing or imagine lifting your chest or lengthening your spine⁽⁵⁾.

How to modify your running when you’re recovering

Psychologically the worst thing to do for a runner is to stop running altogether. Physiologically this is not ideal either, but modifying your volume of running is critically important so to not make the symptoms worse. Commonly, ITB syndrome will present itself at a certain distance every run, so continue to run up to this point, and avoid running beyond. This distance can act as a useful objective marker with regards to progress.

If symptoms are very acute – eg even from the start of a run - consider taking a complete break from running and maintaining your cardiovascular fitness using a non-impact exercise like cycling or swimming. In this scenario it’s sensible to return to running when symptoms and strengthening has improved. There’s no point running through pain. It just keeps the irritability of the knee high and will not allow for full recovery. It’s best to accept that you have an injury and treat it properly so that it goes completely. Generally, ITB syndrome will take between 4-8 weeks to recover if managed appropriately.

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Case study: A 35-year old recreational runner

A good example of how running biomechanics can cause ITB syndrome is that of a 35 year-old recreational runner I treated. She had had left-side ITB pain for a number of months, which had worsened when she’d increased her running frequency from two to four runs per week. She has made a full recovery now, but her technique included all three of the common running faults attributed to the onset of ITBPS as mentioned above:

*From the back view:

1. When she landed with her left foot, it crossed the imaginary line on the treadmill. As a result, her left knee was flung out to the side to allow space for the right knee to swing through.
2. In combination, her opposite hip dropped on impact of the left foot.

*From the side view:

1. Her left foot landed in front of her left hip, therefore classified as an over-stride.
2. As a result of the over-stride, her knee bend was slightly more than the recommended 20 degrees.

*Treatment in the short term:

1. Hip, knee and ankle flexibility work, including dry needling treatment to the hip and thigh.
2. Taping to settle acute symptoms and icing daily.
3. Started a strengthening program with the same aims as the exercises mentioned above.
4. Reduced running frequency from four back to two times per week, and remained at pain-free distances whilst working on the below technique changes.

*Treatment in the long term:

1. Running technique changed using visual and verbal cueing as mentioned above, but not all at the same time. Initially we worked on increasing step rate using a metronome and then increasing her step width.

In total, it took her 6 weeks to be running pain-free at the distances she wanted to achieve.

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References

1. Scand J Med Sci Sports, 2009. March 1-8
2. Sports Med, 2012. Nov 970-992
3. Brukner, P. in: Khan K. 2007 (3rd ed). Clinical Sports Medicine. Sydney. PA: McGraw-Hill Companies.
4. Palastanga, N. 2006 (5^th ed). Anatomy and Human Movement: structure and function. Butterworth Heinemann.
5. Br J Sports Med, 2016. Dec 1-16
6. Iliotibial Band Syndrome: What is it? www.drandyfranklynmiller.com/itbs/