The Truth About IT band Syndrome

IT band

It’s NOT a FRICTION SYNDROME

The purpose of this article is to inform readers that commonly held beliefs regarding ITBS (iliotibial band syndrome) lack evidence and miss the target on treatment. As dedicated exercisers and competitors doing your part to maintain your health, longevity, and push the limits of human performance, you deserve better knowledge and empowerment to keep going. Gaining control over your pain starts with understanding why.

Point 1. Make sure your pain is not caused by something else. Anybody can point to a body part that is painful and give it a name (i.e. runner’s knee and ITBS). The cause of your symptoms is what is valuable to know, and in order understand the cause, the entire movement system (the human body) should be assessed. Lateral thigh and knee pain has potential pain referral from other structures such as the back or hip, not to mention the myriad movement impairments that can occur from the great toe through the spine. Listing differential diagnoses and explaining the relevance of impairments exceeds the scope of this article, but beware, IT band syndrome can be a wolf in sheep clothing. Seeing your physical therapist is an inexpensive first step to establish the factors giving rise to your pain, and ruling out other sources of pain referral.

Point 2. Despite the ‘word on the street,’ IT band syndrome is NOT a friction syndrome or a bursitis. Anatomic research shows there is not even a bursa there!1,2 And, despite the common belief that the IT band tendon slides and rubs back and forth over a bone in the knee, the functional anatomy debunks this phenomenon. Anatomical research has revealed that two slips of tendon with different bony attachments are tensioned at different ranges of knee motion giving the appearance of a band of tissue sliding back and forth. 2  What can occur is compression of a highly vascularized fat pad in that outside part of the knee, which may or may not be the anatomical source of pain.1,2

Well, what about stretching? IT band syndrome is caused by a tight IT band, right?

Point 3. It’s highly unlikely your IT band is too short. Research shows that clinically identified “tight IT bands” are not predictive of IT band pain anyway.3 What’s more, the typical static stretching does not actually lengthen the iliotibial fascia, so why is everybody stretching so much? Let’s review functional anatomy again. Under your skin, your thigh muscles are circumferentially wrapped in a Saran wrap-like tissue called fascia. That fascia is connected all the way down to the back of your thigh bone, running nearly the entire length of the thigh bone. The IT band is simply a thickening of that tissue, and it is not moving anywhere. Consider that a maximal muscle contraction of the TFL causes a 0.2% change in IT band length.1 Furthermore, research shows you are much more likely to be relaxing and lengthening the supportive hip muscles…you know, the muscles you are supposed to be strengthening (see point 4).   Therefore, stretching can actually be counter-productive despite how good it feels while doing it.

Point 4. Strengthening hip girdle muscles has scientific support.4,5 But there is a caveat. It is really easy to strengthen muscles that are already strong, and it is really difficult to strengthen muscles that are relatively weak. It is import to first reeducate your nervous system to recruit specific muscles before strengthening. My mentor always says, “Just because you wear your muscles, does not mean you use them.” So as long as you are recruiting specifically weak muscles, have at it, Jane Fonda. Though not a cure-all, strength and endurance of the hip and pelvic girdle contributes to improved alignment of the lower limb joints while running. What is often the missing component, however, is functional coordination of these muscles while running.

Point 5. Sorry, there is no secret formula for treating IT band syndrome. Passive modalities such as ice, heat, or massage may confuse your nervous system long enough to experience short-lived relief, but the pain will return unless you take a holistic approach to correcting movement patterns. About the foam roller, my professional opinion is that it can help mobilize adhered tissue layers and relieve painful myofascial trigger points (small painful bundles of muscle and connective tissue). However, if the impaired movement is not remedied, those bundles of joy will return.

Point 6. Please, do not give up without a fight. If foam rolling, stretching, icing and general strengthening have been unsuccessful, you now have a better understanding why. So the next time someone proclaimes, “Oh, you just have a tight IT band!” you know better.

My challenge to those who accept that pain is part of who you are as a runner, make time for yourself to learn about how you move. Subtle tweaks can make big changes. Movement is vital to your health, and the precision of your movement is vital to the health of your movement system. Remember, you only have one.

Citations

  1. Falvey EC, Clark, RA, Franklyn-Miller A, Bryant AL, Briggs C, & McCrory PR. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scand J Med Sci Sports 2010; 20:580-587.
  2. Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M. Is iliotibial band syndrome really a friction syndrome? J Sci Med Sport 2007; 10: 74–76.
  3. Devan MR, Pescatello LS, Faghir P, Anderson J. A Prospective Study of Overuse Knee Injuries Among Female Athletes with Muscle Imbalances and Structural Abnormalities. Journal of Athletic Training 2004; 39:263-267.
  4. Nohren B, Davis I, Hamill J. Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomech 2007; 22:951-956.

Article Published in March 2014 issue of Northwest Runner Magazine

Check out Frank Netter’s Atlas of Human Anatomy and related website

Tune-Up Running Form to Reduce Knee Pain

If you enjoy running, but nagging knee pain prevents you from getting your weekly mileage fix, try recalibrating your trunk flexion angle. What is trunk flexion angle you ask? Your trunk flexion angle is the bend at your hips or how far your pelvis and torso are from vertical. A recent study by Teng and Powers (2014) found that increasing the average subject’s trunk flexion angle by 6.8o while running at a controlled speed results in a 6.0% decrease in patellofemoral joint (PFJ) force and reduces torque produced by the quadriceps. On the opposite end of the spectrum, running more upright than one’s self-selected trunk flexion angle [closer to a vertical trunk posture] increases PFJ forces 7.4%.   If sagittal plane [side view] mechanics are one of your most salient flaws, this may be a slam dunk for eliminating knee pain.Trunk lean

 

What does the evidence really mean? The underlying premise is that increased peak forces at the PFJ contribute to mechanical trigger for knee pain. Despite a lack of longitudinal studies to prove this strategy reduces knee pain, one could make the argument that a small reduction in PFJ forces with each step over the entire course of a run is significant. Anecdotally, I have seen this work.

Applying this concept to your running can be difficult without visual feedback.  You can get a close estimate of your trunk flexion angle using a mobile motion capture app such as Ubersense that allows you to draw angles on video captured on your smartphone or tablet. Keep in mind that your speed may affect trunk flexion angle. In the current study, subjects ran at 3.4m/s [7:53min/mile].   Trunk flexion angles between 10o and 18o were associated with reduced PFJ peak forces whereas angles of 1-7o were associated with higher peak PFJ forces.

My advice is to learn trunk flexion angle on a moderately steep hill [~10% grade]. Lean forward slightly from your ankles first, then your hips, and you just might find your gluteal muscles. In my experience, teaching people to run uphill and downhill more efficiently with effective trunk lean and cadence for each task can decrease mechanical stress at the PFJ and in turn, reduce the trigger for mechanical knee pain. Happy running!

Source:

Teng HL, Powers CM. Sagittal plane trunk posture influences patellofemoral joint stress during running. JOSPT. 2014; 44: 785-792.

Does improving hip extension mobility actually improve running economy?

Back, pelvis, and hip deep anatomy (anterior view). Psoas and iliacus flex and laterally rotate in open chain movements maintaining the precise axis of rotation in the acetabulum. In closed chain (standing), they are anterior struts for keeping the body upright and stabilizing the lumbopelvic hip complex. The iliofemoral ligament “checks” excessive anterior translation of the femur head in the acetabulum when extending and medially rotating the femur.

Runners, coaches, and other athletes are always looking for ways to prevent injury and become more efficient and economical while running.  In this example, let’s consider our athlete is the weekend warrior with a 40 hour/week desk job or high school student-athlete. This person sits several hours a day, with maybe a 10-minute walking break every hour. Conventional wisdom is that this person will develop a lack of hip extension due to tight/stiff hip flexors.  The hypothesis is that stiff hip flexors shortens stride length negatively impacting running economy, defined as steady-state oxygen consumption at a given running speed.

So does improving hip extension range of motion in individuals “lacking hip extension” improve running economy? According to the evidence, the answer is NO! Though a 20 year old article, this topic has been researched.1 Subjects were young, athletic male college students determined to have “less than normal hip extension” meaning they were unable to passively extend the thigh past 0 degrees. Subjects were divided into a THREE DAYS PER WEEK (yes that is all) hip flexor stretching group and a control group. On average, hip extension improved 9.8 degrees in those who stretched 3 days per week. Despite a statistically significant change in passive hip extension measured using the modified Thomas Test, improved running economy did not occur. The control group (those who did not stretch) actually showed greater improvement in running economy.

What does this mean practically? Improving hip extension through stretching anterior hip structures does not improve running performance at speeds associated with running at paces one could maintain for 10-20 minutes. Could it actually be counter-productive? From both injury and performance perspectives, YES!  Consider that running at faster speeds requires sufficient anterior stiffness to withstand the forces generated by some of the strongest torque producers in the body; the gluteals and hamstrings. It has been speculated with good biomechanical evidence that excessive hip extension forces and joint angles are associated with injury to the anterior hip joint.2 Furthermore, improving your stride length is not primarily the result of greater hip joint extension range but rather more distance traveled during the float phase of running. This requires power, the perfect combination of force production and timing. A well-timed and stronger stretch-reflex in the hip flexors generates a more powerful hip flexion moment. Finding the optimal blend of stiffness and mobility at exactly the right time is what is important.  Improving economy comes down to practicing a skill and improving timing of force production along with other metabolic processes.

How does this affect you? First, understand the goal of your flexibility exercises. If you are stretching because of hip pain, back off stretching and get assessed by your physical therapist. Stretching could be counterproductive even if you get short-term relief of pain. Are you certain you have limited hip extension? Don’t assume that working at your desk creates short and stiff hip flexors. Videotape yourself from a side view running at fast and slow speeds when you are not fatigued. Do you lose your “neutral pelvis” position. Even if you notice that your low back is arched and your pelvis is anteriorly tilted, do not assume you have stiff hip flexors. This often is a coordination issue that can be addressed through specific trunk and pelvic girdle movement awareness.

Related Blog Posts:

Are you sure your hip flexors are tight? If so, why and who cares?

Psoas, please release me… Let me go!

Does excessive sitting shorten the hip flexors?

Sources:

  1. Godges JJ, McRae PG, Engelke KA. Effects of exercise on hip range of motion, trunk muscle performance, and gait economy. Phys Ther. 1993; 73:468-477.
  2.  Lewis CL, Sahrmann SA, Moran DW. Effect of hip angle on anterior hip joint force during gait. Gait and Posture. 2010; 32:603-607.

Post Joint Mobilization Recommendations

What is mobility without control?  A recipe for injury and loss of training time.

The purpose of this blog post is to highlight the need for more of us to follow through with the process of restoring function after gaining mobility.   Specifically, I want to highlight that the goal after gaining mobility is to achieve the neuromuscular control and  tissue resilience to handle the load demands placed upon the body in that increased joint range.

Joint mobility can be achieved through stretching, repeated movements, or manual techniques.  Phyical Therapists will use manual (hands on) joint mobilization techniques to improve joint accessory motions and physiological motions so a client can perform a desired task without pain or pathologic movement.  Physiological motions refer to gross movement such as flexion, extension, and rotation movements. An example is bringing the thigh toward the chest to create hip flexion.  Accessory motions refer to how the joint surfaces move against one another.  For example, when the head of the femur is laterally rotated on the acetabulum (hip socket)  in an open kinetic chain (when the leg is not in contact with the ground), an accessory anterior and superior glide of the femur on the acetabulum occurs.  In a healthy movement system, accessory motion should be held in check by passive structures such as ligaments and cartilage (labrums, meniscus, etc.) and controlled by precise coordination of muscles around the joint.  In theory and clinical application, maintaining a precise center of rotation is desirable.  Though not a perfect example, consider a suspension bridge without sufficient control to limit excessive motion. (See Tacoma Narrows Bridge collapse below).

*Skilled assessment should always be performed prior to attempting self administered forceful joint mobilization techniques.  Hypermobility is contraindicated.  Remember that just because a structure feels “tight” does not mean that the structure needs mobilization.  “Tightness” is a sensation! 

I am a prime example for this blog post.  3 years ago, I enjoyed a gnarly grade II inversion ankle sprain overstretching my left lateral ankle ligaments.   Recently I have had midfoot pain with running or hopping on one foot and it was increased on for 24-48 hours after long runs.  A few colleagues assessed my ankle and foot finding key findings limited active/passive dorsiflexion and restricted mid foot pronation (functional and passive) among other impairments.  Following manual joint and soft tissue mobilization techniques, I had no pain with repeated single leg hopping and my percieved ability pronate the foot improved.  With improved pronation, my lower extremity should more effectively absorb impact forces compared to my baseline at initial assessment.  However, my lower extremity needs to do this in a coordinated fashion.

My simple post mobilization regimen has been

1. Activity modification (reduction in volume and intensity of runs for 2 weeks)   2.  Single limb balance on level and uneven surfaces, with single limb squat .  3. Low load eccentric calf strengthening x1 to fatigue 4.  Single leg hopping x1 to fatigue

 

 

Opinion on Vibram Five Fingers Lawsuit

If you have not heard yet, Vibram USA Inc. has settled a class action lawsuit to pay back consumers who bought their FiveFingers footwear after March 2009 for claiming false health benefits.  The premise for the suit is that the shoemaker claimed wearing the shoes could strengthen foot muscles and serve as an injury prevention strategy.  Vibram USA did not have scientific evidence to directly support their claims.  The $3.75 million set aside for consumers to claim as a refund will be available in the near future.

Marketing is what companies do to attract consumers to buy a product, so would I expect anything less from Vibram? No. Is the $3.75million a big deal to them? I don’t know, but it was probably worth the cost of making the deceptive claims.

My question: At what point do consumers start to understand the quick fix for injury is a myth? If you honestly believed a wholesale change to running “barefoot” would prevent injury, I’m sorry…Go get your money.

The truth is, the marketing claims were not necessarily 100% wrong, but neither were they totally accurate.  Deceiving? Sure.  Vibram’s issue is making claims based upon anecdotal evidence and applying it a large group of people.  Wake up! They are not the only company or individual’s doing this.

I personally used FiveFingers during the winter of 2008 to run “barefoot” on frosted field turf as I recovered from an Achilles injury.  Did it help me?  Probably, but not in isolation. I consulted with a physical therapist and coach, chose proper nutrition, cross trained, progressively returned to running, and worked on my running technique and proprioception.  Did I buy another pair?  Yes, FiveFingers were really comfortable to wear on field turf when it was cold out.

Would I recommend FiveFingers to a client?  It depends.

Footwear is not a magic bullet.  Strengthening, injury prevention, and rehabilitation is rarely attributed to a product, new exercise, or stretching technique.  It is multifactorial, and it is depends on the individual.

Don’t be duped next time.

 

No, I will not be asking for a refund.