The TRUTH about ITB syndrome!

This article takes about 5minutes to read and maybe a few more minutes to review key points!

ITB Syndrome is all around me, I regularly have friends, colleagues, clients suffering from it and asking questions,  I get emails asking for information, all have something in common; can’t get rid of the pain, discomfort and are limited to the training they can do.

I also frequently see on social media posts about the 3 miracle exercises or the best stretch for ITB syndrome, well wish it was that easy, but no:)  So I decided to write this article to educate the athlete and give some constructive info to understand better this stubborn overuse injuries that can be very debilitating and painful. Enjoy!

The Myths behind ITB Syndrome
There is many misconceptions when it comes to the cause, diagnosis and treatment of the injured Illiotibial band. Often the blame is put on the knee, an inflammation, the athlete is told to stretch and/or foam roll and rest. The athlete spend too much time away from training without much result at the end. ITB syndrome is an overuse injury due to poor mechanics and form, amplified with higher volume of training.

ITB compression is a major issue among mountain runners and endurance cyclists.

ITBC presents with an incidence rate of up to 22% in all lower extremity running-related injuries and has been stated to be the second most frequent complaint among distance cyclists and runners (first is hamstrings), and a higher rate with endurance athletes.

ITB compression syndrome is a non-traumatic overuse injury and is the most common cause of lateral knee pain in athletes. The discomfort is on the inferior lateral aspect of the knee.

Figure 1: ITB and surrounding muscles

Screen Shot 2018-10-17 at 5.28.49 PM

Friction versus compression
ITB friction syndrome was originally thought to be caused by repeated flexion and extension of the knee causing friction of a bursa by the overlying ITB, which often called and diagnosed as the ‘runners knee’, good news you don’t have a runners knee! In recent years, however, the pathophysiology of this condition has been well researched and clarified and it’s a compression rather then a friction that occurs at the knee. ITB compression syndrome occurs at between 30 and 60 degrees of knee flexion. MRI scans have ascertained the knee flexion angle of 30° elicited the greatest compression of the ITB at the point of foot strike.

The ITB actively function to resist hip adduction and hip & knee internal rotation.

Figure 2: Notice the ITB lengthening position on the right leg is greater compared to the left which is due to muscular imbalances creating greater hip adduction and internal rotation causing compression at the knee – the ITB is put under tension creating compression at the distal attachment on the lateral knee.
Screen Shot 2018-10-18 at 10.18.41 AM

Based on its attachments at both the knee and hip, biomechanical dysfunction often contributes to the onset of ITB compression.

As the knee flexes and extends the ITB ‘slides or flicks’ over the lateral femoral condyle of the knee causing an irritation to the fat pad beneath. 
The cause of pain is due to increased strain of the ITB crossing the lateral femoral condyle. This highly vascularized connective tissue is the pain-producing structure in ITB compression syndrome.

Athletes such as endurance runners & cyclists who perform repetitive knee flexion and extension combined with repetitive loading are exposed to this condition.

Main causes of ITB compression:
Musculoskeletal imbalances
Postural weaknesses
Poor form (eg: downhill running)
Overactive TFL
Hip flexors dominance
Weak or inhibited gluteus group
Weak or inhibited abductors & external rotators

Biomechanical factors that increases tension on ITB:
Poor foot control
Increased hip adduction & internal rotation
Poor lumbopelvic control
Limited ankle range of motion
Overstriding with heel strike dominance
Slow stride rate

The musculoskeletal imbalances are increased in the downhills and it’s often when the athlete start feeling discomfort on the lateral knee within mid-stance. Unfortunately, symptoms progress from there if poor form and training volume are kept the same or increased.

Downhill Running produces greater knee flexion angle at the point of foot strike eliciting a greater strain load to the ITB therefore often a primary precursor to ITB compression. Although an increased knee flexion angle at the point of foot strike has been considered to contribute to ITBC. Overstriding, heel strike dominance and hyperextension at the knee will also produce greater strain loads on the ITB at the three distal attachments.

Downhill running technique is too often overlook and has a great influence on the negative stress load on the ITB.

Causes of ITB discomfort during downhill running: 
Poor foot control
Weak VMO
Weak gluteus medius
Poor quadriceps eccentric strength
Weak lower leg muscles
Overactive TFL

Cycling and the ITB
ITB injuries in cyclists are usually the result of training errors and poor bike fitting. Foot–pedal force, knee flexion angle and crank angle should be examined as they relate to the causes of ITB issues. Repetition of the knee in the impingement zone during cycling appears to play a more prominent role than force. The ITB may be further aggravated by improper seat position, anatomical differences, and training errors while cycling.

Poor technique
Poor bike fitting

To focus on:
Bike fit
Proper riding position
Pedaling mechanics

Guidelines for athletes suffering ITB compression syndrome
Key zones to prehab:

Foot stability (standing and barefoot exercises)
Lower leg strengthening
Functional lumbopelvic stability (sports specific exercises)
Functional knee alignment exercises
Neural gluteus maximus drills
Hamstring eccentric loading

Treatment should be directed towards addressing the biomechanical causes.

Weekly physiotherapy sessions including deep fascial release work in the surrounding muscles
Form training (sports specific drills)
Cold water treatment (spray daily ITB for 30s+)
Stretching and deep tissue massage in the hip flexors and TFL
Focus on posterior muscle strengthening and correcting any musculoskeletal imbalances
When performing exercises focus on proper form and postural alignment

To avoid:
Stretching and foam rolling the ITB
Deep lunges & squats
Exercises with knee flexion beyond 20 degrees in first few weeks of tenderness
Hip abduction exercises without external rotation (need external rotation which is often overlook in rehab)
Leg extension machine
High volume training
Downhill running with poor form
To stop exercising! (keep moving)

The cause of ITB compression syndrome are multifactorial, get inspired and prevent the overuse injury by focusing on the above key points. If you do suffer from ITBCS get an assessment done real soon, reduce your training volume and stay away from downhill running or steep and long rides. Skiers are also prone to ITBCS due to force put upon the knee. Take good care of yourself before winter starts!

Important: this article is an introduction to ITB compression syndrome to create awareness and educate the athlete.
If you suffer from ITBCS I highly suggest you consult a rehab specialist in running/cycling who can do a thorough assessment of your mechanics and musculoskeletal imbalances. Rehab/prehab should focus on both form retraining and correcting the imbalances. The longer you wait to deal with the issue the longer it will take to heal since the ITB is a thick, stubborn and strong fascia. The symptoms will diminish only when biomechanical improvements occur, releasing tension on the joints and creating proper alignment from the hip down to the knee and to tibia & fibula. The surrounding muscles will be advantage and should fire with proper timing.

Sports rehab specialists, coaches and passionate athletes reading this article and interested in learning more about ITB compression syndrome I offer an 8hrs to 20hrs courses specifically on assessment, treatment, prevention including prehab exercises & drills for the runner and cyclist.
Biomechanical causes of ITB Compression in endurance cyclists and mountain runners

Stay in touch,  email me your thoughts!

Thanks for reading… Chloë

Monthly educational articles for the passionate mountain athlete.

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