Iliotibial Band Syndrome

Iliotibial Band Syndrome or ITBS is common injury among runners and cyclists, which affects the Iliotibial band (IT Band) that runs from the hip to the knee along the lateral side of the thigh. There are a few possible causes, but mostly this injury is related to overuse and repetition. This results in pain on the lateral side of the knee, and during extension and flexion of the knee, which can have quite a sudden onset. It can usually subside quite quickly with proper management, however some people have ongoing pain and problems with their IT Bands.

What is the IT Band?

Before I describe the injury in more detail, it is best to have a clear picture of what the IT band actually is. But this isn’t an easy question to answer. Yes, despite the fact that us humans have a complex understanding of galaxies many million miles away, we still have very limited knowledge about the IT Band, as well as many other aspects of the human body. As previously stated the IT band runs along the lateral thigh from the hip to the knee, and it blends with the fascia in the upper thigh at the proximal end (thigh end), and blends with the knee capsule at the distal end (knee end), where it attaches to the top of the tibia (shin bone). It also acts as the tendon of the Tensor Fasciae Latae (TFL) which is a very small muscle at the top of the lateral side of the thigh, as well as the glutes.

Given that the IT band acts as a tendon, it would be easy to assume it is just another tendon, but that’s not the whole truth. Would it be better described as a ligament since the IT band is directly connected to both the pelvis and the knee? Ligaments connect bone to bone so this adds up. But ligaments do not connect muscles to bones (that’s what tendons do), so the IT Band acts as both a ligament and a tendon. It could be called a hybrid of the two, but even this does not fully explain it. A bit of a head scratcher right?

The IT Band is generally accepted to be both a tendon and a ligament, but also a thickened area of fascia that is interconnected with the fascial network, and composed of collagen which is non-elastic and therefore very strong and stiff. Tendons, ligaments and fascia are all essentially part of the same network of connective tissue, so really all of the names are correct. None of them are right or wrong, nothing acts quite like the IT Band does.

What is IT Band Syndrome?

IT Band Syndrome is an injury relating to repetition and overuse during activities such as running and cycling. Symptoms of the injury are primarily knee pain – especially on the lateral side of the knee. For a long time it was considered to be a friction related injury, caused by the movement of the IT Band over the lateral femoral condyle (the bump on the outer edge of the femur); however this is now considered to be an outdated understanding, because it is thought that the IT Band does not actually move and is firmly attached at the knee.

A recent study suggested that the actual cause may be compression of fat tissue between the IT Band and the lateral femoral condyle, and the pain is experienced due to the large numbers of nerves in this fat tissue.

So that settles it right? It’s all about compression and not friction. Well maybe not. Another study showed possible evidence for movement of the IT Band during knee flexion and extension, but given the clear contradictions between the studies, it’s safe to assume that the jury is still out on the topic, and the actual cause of IT Band Syndrome is yet to be agreed on by researchers.

There are a number of risk factors associated with IT Band Syndrome. Generally speaking, any issues with your gait and posture affect how you walk, distribute weight and the degree of tension put on the various joints and muscles. Something like a leg length discrepancy (which is more common than you might think) can be a risk factor, as well as genu varum (bow legs) and overpronation of the ankle (ankle rolls inwards).

Treatment for IT Band Syndrome

In the acute stages, the RICE protocol is usually recommended. RICE stands for rest, ice, compression and elevation, which is a standard protocol for muscular injuries and pain. There is the ongoing debates about whether ice should be used or not in general for injuries, but I am going to put this debate to one side for this article. For the most part rest from the activity that caused the problem is usually best, however when the activity is started again it can just lead to a worsening of the problem.

There is also the topic of stretching which is controversial to say the least when it comes to the IT Band. Some studies state that the IT Band is essentially too stiff to stretch. Most notably a 2008 study was conducted which found that it took over 900kg of weight to stretch the IT Band by 1%. Some studies have suggested that the IT Band can in fact be stretched, however there is ongoing debate (again). Regardless of whether lab based studies have found ways to stretch the IT band, it turns out to be incredibly difficult to do by ourselves, both because the level of force needed to stretch the IT band isn’t possible, and because we end up just stretching the surrounding muscles and tissue instead.

So what about manual therapies and massage? Well, massaging directly on the IT Band is questionable in it’s effectiveness – mainly because of the stiffness of the fascia and it’s lack of stretch, so this is probably not going to have any impact at all. However, soft tissue work in the surrounding regions including the lateral quads and hamstrings, as well as the glutes can be very beneficial, as it is tension in these areas that can create problems with the IT Band.

Conclusion

I think it’s safe to say the IT Band is a very controversial body part. Who would’ve thought it? We don’t really know what causes IT Band syndrome, and we can’t even agree on whether the IT Band moves or not. The IT Band is a paradox, and a very unique piece of fascia, which can cause a lot of chronic issues for some people. The good news is that it tends to be an injury that can subside and improve over time.

References

Chaudhry, H., Schleip, R., Ji, Z., Bukiet, B., Maney, M. and Findley, T., 2008. Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy. Journal of Osteopathic Medicine, 108(8), pp.379-390.

Cruells Vieira, E., Vieira, E., Teixeira da Silva, R., dos Santos Berlfein, P., Abdalla, R. and Cohen, M., 2007. An Anatomic Study of the Iliotibial Tract. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 23(3), pp.269-274.

Fairclough, J., Hayashi, K., Toumi, H., Lyons, K., Bydder, G., Phillips, N., Best, T. and Benjamin, M., 2007. Is iliotibial band syndrome really a friction syndrome?. Journal of Science and Medicine in Sport, 10(2), pp.74-76.

Fairclough, J., Hayashi, K., Toumi, H., Lyons, K., Bydder, G., Phillips, N., Best, T. and Benjamin, M., 2006. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of Anatomy, 208(3), pp.309-316.

Ingraham, P., 2017. IT Band Stretching Does Not Work. [online] http://www.PainScience.com. Available at: <https://www.painscience.com/articles/iliotibial-band-syndrome-stretch.php#acknowledgements&gt; [Accessed 6 September 2021].

Ingraham, P., 2021. IT Band Syndrome—What works? What doesn’t? Why? [2021]. [online] http://www.PainScience.com. Available at: <https://www.painscience.com/tutorials/iliotibial-band-syndrome.php&gt; [Accessed 5 September 2021].

Jelsing, E., Finnoff, J., Cheville, A., Levy, B. and Smith, J., 2013. Sonographic Evaluation of the Iliotibial Band at the Lateral Femoral Epicondyle. Journal of Ultrasound in Medicine, 32(7), pp.1199-1206.

Mark Wilhelm, K., 2021. DEFORMATION RESPONSE OF THE ILIOTIBIAL BAND-TENSOR FASCIA LATA COMPLEX TO CLINICAL-GRADE LONGITUDINAL TENSION LOADING IN-VITRO. [online] PubMed Central (PMC). Available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5294943/&gt; [Accessed 5 September 2021].

Norris, C., 2019. Sports and soft tissue injuries. 5th ed. Oxon: Routledge, pp.157 – 160.

Reuell, P., 2015. Understanding the IT Band. [online] The Havard Gazette. Available at: <https://news.harvard.edu/gazette/story/2015/08/understanding-the-it-band/&gt; [Accessed 5 September 2021].

Scarr, G., 2017. 5 things you need to know about your IT band. [online] Runner’s World. Available at: <https://www.runnersworld.com/uk/health/injury/a775743/5-things-you-need-to-know-about-your-it-band/&gt; [Accessed 6 September 2021].

Seeber, G., Wilhelm, M., Sizer Jr, P., Guthikonda, A., Matthijs, A., Gilbert, K., Matthijs, O., Lazovic, D. and Brismée, J., 2020. THE TENSILE BEHAVIORS OF THE ILIOTIBIAL BAND – A CADAVERIC INVESTIGATION. [online] PubMed Central (PMC). Available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296993/&gt; [Accessed 7 September 2021].

Walker, B., 2013. The anatomy of sports injuries. 2nd ed. Chicester: Lotus Publishing, p.181.