2 Exercises to End Iliotibial Band Syndrome
Previous blog: 9/08/2018
Reading time: 5 minutes
Increased activity and knee pain go together like peanut butter and jelly. Iliotibial Band Syndrome (ITBS) is one of the top five injuries affecting runners. (1) The Iliotibial band is a frequent recipient of overuse stress. This blog will provide an updated etiology and best practice management for ITBS, including a crucial rehabilitation strategy that every evidence-based chiropractor should consider.
Watch Dr. Steele explain how to manage ITB syndrome successfully. Hint: focus on strengthening the glutes instead of stretching the Tensor Fascia Latae (TFL)
Historically, therapists would use ice and rest to alleviate symptoms at the lateral knee. This treatment does not match 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. So, ice and rest will not correct the problem.
The distal portion of the band does not "snap" back and forth during knee flexion and extension. (2,3) 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.
What Causes ITBS?
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 the gluteus medius and maximus fatigue. 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; research confirms that strengthening the glutes will correct this imbalance and reduce symptoms of ITBS. Most patients who incorporate hip abductor strengthening into their ITBS rehab will experience symptom resolution within six weeks. (5,6) Also, consider that the dense fibrous iliotibial band is exceptionally resistant to stretch (less than 0.2% with maximum voluntary contraction), so flexibility gains must come from the TFL.
Strengthening the hips without loading the IT band proves to be a challenge. Rehabilitation requires progressively loading the glutes without loading the TFL.
How do you strengthen the glutes without activating the TFL?
Unfortunately, most ITBS patients have weakness in the gluteus medius and maximus on the affected side. Strengthening the glutes without over-activating the TFL is vital, 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.” (4)
There is a clear winner: The clam exercise with and without resistance
The clam exercises demonstrate the highest GTA index. Include them with your next patient with ITBS! This paper by Fetto concurs with earlier theories that clam exercises with and without resistance are preferred for hip abductor strengthening with minimal TFL activation. (3)
Clam
Clam with Band
In addition to home exercise, counsel your athletes on activities of daily living:
Activity modification may require a 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, requiring greater TFL activation for stabilization.
Runners must avoid "crossover" gaits, which aggravate iliotibial band problems.
Cyclists may need to adjust the seat height and avoid “toe-in” pedal positions.
Initially, patients should avoid; stair climbers, squats, and deadlifts.
Athletes should consider new training shoes, particularly if the current shoes have over 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 Clinical Skills section. We update all 95 diagnoses regularly, so you and your patients are armed with essential 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.
BONUS Material: Should I Foam Roll the IT Band?
For Stretching: NO
"A single episode of stretching and foam rolling does not affect short-term ITB stiffness." (7)
For Pain Relief: YES
Foam rolling, however, does decrease pain. Sulowska-Daszyk et al. (2022) found that patients should incorporate self-myofascial release techniques with foam rollers in the daily training routine of long-distance runners for pain relief. (8)
For more information on HOW manual therapy affects the soft tissue (including instrument-assisted, foam rolling, and myofascial release), check out this blog by Todd Riddle of FAKTR. It is one of my favorites on manual therapy!
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Kakouris N, Yener N, Fong DT. A systematic review of running-related musculoskeletal injuries in runners. Journal of Sport and Health Science. 2021 Apr 20. Link
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.
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.
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
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.
Pepper TM, Brismée JM, Sizer Jr PS, Kapila J, Seeber GH, Huggins CA, Hooper TL. The Immediate Effects of Foam Rolling and Stretching on Iliotibial Band Stiffness: A Randomized Controlled Trial. International journal of sports physical therapy. 2021;16(3):651.
Sulowska-Daszyk I, Skiba A. The Influence of Self-Myofascial Release on Muscle Flexibility in Long-Distance Runners. International Journal of Environmental Research and Public Health. 2022 Jan;19(1):457.
