By: Genevieve Ward
Genevieve is a registered massage therapist at Body Poets who mixes other activities with running to keep her IT band happy.
If you run, cycle, or walk for exercise, you know about the iliotibial band, or ITB, on the outside of the thigh, and during exercise you might have suffered from pain at the knee that is known as Iliotibial Band Friction Syndrome or ITBS.
I have personally gone through problems with ITBS.
Starting four months out from a half marathon, I was only able to run 3 km before the pain would take over. Thankfully, mixing what I learned as a RMT with some more research and experimenting, I was able to finish my half marathon pain-free and make my goal time. I’d like to share what I learned with you.
So why do we have this ITB?
It’s not a muscle, it is a superficial layer of fascia that helps move the hip and stabilize the knee. It’s like the plastic wrap to keep everything safe and in its place, and to keep all actions happening as they should.
The Iliotibial band is a broad tissue that attaches up at the lateral hip bone along the iliac crest. It also meshes with two hip muscles, tensor fasciae latae (TFL) and gluteus maximus. Then it runs down the thigh over the top of the leg bone (the greater trochanter) and along the side of the thigh to narrow into a thick rope, cross the outer side of the knee, and travel down to the outside of the shin (the tibia). As it crosses the knee joint, some fibres mesh with the front of the knee cap (patella).
Up at the hip, the tensor fasciae latae is like the ITB’s little teammate, sitting anteriorly to the ITB and attaching at its top to the iliac crest, with its other attachment being the ITB itself. In the back, the glute max fibres merge into the ITB as well, and between them, these three structures have the front, back, and side of the hip covered.
Down at the knee, it’s the same kind of story, with the ITB and patellar fibres attaching at the top of the tibia in the front, the hamstring tendon attaching in the back, and the peroneal muscles running below them to the ankle. It’s all one sling of support and movement potential.
The ITB kicks in as a knee stabilizer when the knee when it is straight and when it is somewhat bent – when we’re leaning forward against gravity with a slight bend, or when we lift the opposite foot – and it is constantly moving back and forth across the outer side of the knee cap during running, cycling, and walking movements.
This constant movement across the knee and the meshing of fibres with the patella explains why Iliotibial Band Friction Syndrome or ITBS is a very common condition that runners face, and why it can also occur with other sports and activities whenever the ITB it is irritated by repetitive motion that causes it to rub against bones or other structures.
Signs and Symptoms
You’ll know you have an IT band problem if you feel pain or irritation at the lateral side of the knee joint.
As it worsens, you’ll feel it all along the outer side of the leg, especially when the knee is bent to 45 degrees. At the start it can be pain-free until a few kilometers in to your activity; and most likely it will force you to cut short your outing. The outside of your leg will feel painful, inflamed, and contracted. If you do continue, commonly the pain will increase and your knee movement will become like the tinman in need of oil. Pain can continue for a day or days and be constant with walking even if you try to push through it. That being said, ITBS is not something you want to push through.
But we don’t always get ITBS, so why does it occur? Reasons are misalignment in the knee from certain muscles or structures being too tight or too weak; increasing our activity too much at once for the body to be able to adapt; or possibly structural issues like over-pronation, one leg being longer than the other, or sometimes bow-leggedness.
What Should I Do?
There are multiple ways to help keep a healthy, happy ITB.
Try different things and see what works for you. Create your own mix. Realize that it will be a maintenance routine, not a onetime fix. Just like you have to train to increase your kilometers and improve your time, you have to maintain the machine!
I know this seems simple but I think it’s forgotten sometimes. Doing a few different exercises before activity to wake up your gluteals, low back, quads, hamstrings, and abs (in other words, your lower cross section) will help to ensure all surrounding muscles are active and doing their part.
Variety is the spice of life
I definitely made this mistake when I first started running again as an adult: not enough variety in my activities! I liked running, so I just ran. It didn’t work out well. Find other exercise or activities you like to do. It’s really helpful to create balance and strength in your muscles. It can be doing different workouts at the gym, biking, swimming, or yoga. As well, mix up your running, having slow long runs, goal-time runs, hill runs, and walk-run days.
At the start of my rehab I could do only two days of running within my pain free bounds, with a day of strengthening, a day or two of yoga, and lots of biking added in.
Ah, the love/hate relationship we can have with stretching. If you’re having ITBS, stretching can make the difference between it being a mild pain you got briefly when you were running, and a pain that’s staying around and decreasing your running greatly. You should do a good low body and low back stretching post-running. I’ve found stretching my quad/tensor fasciae latae and gluteals to be the most important, due to how they mesh and connect with the ITB. If you find a particular short muscle and the stretch feels comfortable, holding it for longer than 60 seconds or doing a few rounds of stretching with it can help.
If you do yoga, think of it like the difference between the first downward dog and the last one in a session. The last one will be easier and deeper. If you struggle to get yourself to stretch it can be good to start by doing at least one or two stretch sessions a week, and see if you can build up to several times a week.
Some people say yes, some say no. There’s debate about using foam rollers. I found it helpful in lengthening and getting some good blood flow into the area. Make sure you’re not rolling solely up and down the side of your leg/ITB, but also into your glutes, TFL, hams, quads, and back. If you find it too painful, play with levels of cushion between you and the roller, like a yoga mat, rug, or blanket. Do what feels good.
We hear a lot about stretching but strengthening may be even more important in correcting imbalances from side to side or front to back.
If your back and your lower body muscles are strong and balanced, they will support you as you move and help avoid injuries. If one muscle group isn’t working as it should, other muscles will have to take over and do jobs they are not meant to do. You know what happens when you do someone else’s work over and over on top of your own job. You get overtired and cranky, and maybe you complain a lot. It’s the same for the muscles.
One muscle group that can cause ITBS for a lot of people when it’s weak, especially women (because having wider hips changes the angle between the hip and knee and puts more stress on the knee) is the gluteus medius, gluteus minimus, and tensor fasciae latae complex. These muscles’ main movement is abduction of the hip – when you lift your leg out to the side.
How often do you do that motion? Not often enough to keep these little guys strong. Instead, they are often forgotten and under-used, or even over-stretched by our posture, making them weak, and possibly causing an imbalance that affects the ITB.
The simplest way to check whether this is an issue for you is to lie on the floor on your side, resting your upper body on your forearm, and with the lower body straight. Then slowly lift the top leg up towards the sky with your foot flexed as if you were standing on it. I found the first time I did this movement I could tell right away my lateral hip muscles were weak and I could only lift my leg a few times. To strengthen these muscles you can continue doing the exercise above – called side-lying hip abduction – along with the clam, standing abduction, curtsey squat, and squat, and working up to a one-legged squat as your muscles get stronger.
I found massage really helpful for my ITB issues.
One, it helped to calm and relax my ITB by getting some length, getting more mobility, breaking down adhesions, and getting blood flowing into the area to repair and make the tissue healthy. Two, I also found getting the surrounding muscles (quads, calves, glutes, hams and low back) worked on both helpful and informative. Massage released tension for those muscles and even better, it showed me exactly what muscles were short, tight, and weak. It gave me a better map of my imbalances so that I could navigate them. Massage really helped me to understand what was happening in my body and helped me to make changes and work on muscles appropriately.
These things helped me recover from ITBS:
- Play with the way you move when you run. Try different running styles
- Put some time and research into the shoes you pick
- Slowly build your kilometers, working with your recovery from ITBS
- Ice on the painful area is good if there’s acute pain post-run; use heat in the following days
- Make sure your running surface is flat and avoid running on concrete, especially during recovery
Ask your RMT to help you with any of these things. We are here to help you figure out what’s going on in your body, and we can develop an exercise recovery and maintenance routine that works for you!
Read more about the leg muscles and how to care for them in some of Body Poets’ other posts: