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Increased activity and knee pain go together like peanut butter and jelly.  The Iliotibial band is a frequent recipient of overuse stress. This blog will provide an updated etiology of the best practice management for Iliotibial Band Syndrome (ITBS), including a crucial rehabilitation strategy that every evidence-based chiropractor should consider.

Watch Dr. Steele explain how to successfully manage ITB syndrome. (Hint: focus on strengthening the glutes instead of stretching the TFL)

Historically, therapists would use ice and rest to alleviate symptoms at the lateral knee.  This treatment was based upon a false understanding of the etiology of ITBS. Earlier theories suggesting that ITB syndrome was a “friction syndrome” resulting in irritation to a distal bursa are wrong on two accounts – there is no bursa, and the distal band does not undergo friction-inducing movement.  The distal portion of the band does not “snap” back and forth during knee flexion and extension. (1,2) The illusion of a forward to backward displacement during flexion results from an alternating tension between the TFL and gluteus. When the knee is straight or only slightly flexed, TFL tension predominates, causing the anterior fibers of the ITB to become more prominent.  As the degree of knee flexion increases, stress from the gluteus maximus makes the posterior fibers of the ITB more prominent. (Skeptical biomechanists can perform a self-demonstration by simultaneously palpating the anterior and posterior aspects of their ITB while slowly squatting from a single leg standing position.)

So what is causing ITBS?

Simply – hypertonicity or overdevelopment of the TFL and underutilization of the glutes predisposes patients to ITBS.  This problem is common in runners; particularly during longer distances when increased knee flexion and adduction occur secondary to fatigue of the gluteus medius and maximus. This results in repetitive eccentric loading to the posterior fibers of the ITB.

The knee is servant to the mechanics of the hip and foot; and research confirms that strengthening the glutes will correct this imbalance and reduce symptoms of ITBS. In fact, the vast majority of patients who incorporate hip abductor strengthening into their ITBS rehab will experience symptom resolution within six weeks. (4,5)  However, strengthening the hips without facilitating the TFL proves to be a challenge.

How do you strengthen the glutes without activating the TFL?

Unfortunately, most ITBS patients present with weakness in the gluteus medius and maximus on the affected side. Strengthening the glutes without overactivating the TFL is key and new research has examined how to accomplish this goal:

Strengthening and activation of the gluteus maximus and gluteus medius while minimizing the contribution of the tensor fascia lata are essential components in the treatment of many lower limb injuries. Previous researchers have evaluated a myriad of exercises that activate the gluteus maximus (GMax) and gluteus medius (GMed), however, limited research has been performed describing the role of the addition of elastic resistance to commonly used exercises. The primary purpose of this study was to determine the gluteal-to-tensor fascia latae muscle activation while performing 13 commonly prescribed exercises designed to target the GMax and GMed. The secondary purpose of this study was to compare muscle activation while performing a subgroup of three matched exercises with and without elastic resistance.” (3)

There is a clear winner: The clam exercise with and without resistance

The clam exercises demonstrated the highest GTA index and should be strongly considered in ITBS rehab protocols. This concurs with earlier theories that clam exercises with and without resistance are a preferred mode of hip abductor strengthening with minimal TFL activation. (2)

Click here to see a video demonstration of the

In addition to home exercise, athletes should be counseled on activities of daily living:

  • Activity modification may require lower duration of exercise but not necessarily pace. Fast-paced running is less likely to aggravate ITB problems when compared to slower “jogging’.
  • Patients should begin slowly and increase their distance by no more than 10% per week.
  • Runners should minimize downhill running and avoid running on a banked surface like the crown of a road or indoor track. Running on a small circular track causes the inner leg’s ITB to work harder to prevent it from swinging medially. If track work is unavoidable, runners should reverse directions each mile.
  • Athletes should avoid running on wet or icy surfaces as these require greater TFL activation for stabilization.
  • Runners must avoid “crossover” gaits, which have been shown to aggravate iliotibial band problems.
  • Cyclists may need to adjust seat height and avoid “toe-in” pedal positions.
  • Initially, patients should avoid; stair climbers, squats and dead lifts.
  • Athletes should consider new training shoes, particularly if the current shoes have in excess of 300 miles or show signs of wear on the lateral heel.

For a complete synopsis of the best practice management of ITBS, be sure to refer to ChiroUp’s condition reference under the Sharpen my Clinical Skills section.  We update all 95 diagnoses on a regular basis so you and your patients are armed with the most important information.  As always, send us your comments and criticisms so we can continue to shape ChiroUp into the most valuable resource for evidence-based chiropractors.

Still not a member of ChiroUp?  That’s okay.  We’re not going anywhere. We encourage you to send in your ideas to info@ChiroUp.com.  Hopefully, we can someday become a partner in your practice that provides unsurpassed value to both you and your patients.

1. Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat, 2006;208:309-316.
2. Michaud T. The Real Cause of Iliotibial Band Syndrome Dynamic Chiropractic November 18, 2012, Vol. 30, Issue 24
Fetto J, Leali A, Moroz A Evolution of the Koch model of the biomechanics of the hip: clinical perspective. J Orthop Sci. 2002; 7(6):724-30.
3. Barton N. Bishop, Jay Greenstein, Jena L. Etnoyer-Slaski, , Heidi Sterling, Robert Topp. Electromyographic analysis of gluteus maximus, gluteus medius, and tensor fascia latae during therapeutic exercises with and without elastic resistance. The International Journal of Sports Physical Therapy Volume 13, Number 4 August 2018 Page 669
4. Fredericson M, Cookingham C, Chaudhari A, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med, 2000;10:169-175.
5. Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment. Sports Med. 2005;35(5):451-9.

About the Author

Dr. Brandon Steele

Dr. Brandon Steele


Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

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