IT Band pain syndromes are one of the leading causes of knee pain in runners.  While many theories have been presented regarding increased levels of friction at the lateral femoral condyle, “tightness” of the IT band itself, and repetitive flexion and extension of the knee under load, much remains unknown regarding the onset of dysfunction.  One particularly meritorious observation is that altered lower extremity movement in a variety of joints is evident in those presenting with ITBS.  Additionally, there is markedly decreased strength in a predictable pattern in those with ITBS.

While many people attempt to treat the problem as a local issue, the anatomy of the Iliotibial band is far more complex and can be influenced not only locally, but also proximally and distally.  The IT Band itself rises from the gluteus maximus, gluteus medius, and TFL and inserts into the lateral femoral condyle and to the infracondylar tubercle of the tibia.  It is also believed that the IT Band serve as a passive restraint of knee internal rotation and adduction.  Because of it’s complexity one must take into account the interplay of the rearfoot and ankle as well as the function of the hip.

At the rearfoot, we know that excessive pronation can result in a relative internal rotation of the tibia, which will, in turn, lead to unnecessary torsion on the distal end of IT band.  Stiffness in the ankle mortise, a common finding in distance runners, necessitates increased abduction of the foot and/or calcaneal eversion to compensate for a lack of dorsiflexion.  While it is subject to debate, increased rates of eversion have been correlated with ITBS in runners.  Additionally, some recent research by Ferber and Colleagues has demonstrated increased ankle invertor moments in subjects with ITBS and greater inversion angle at ground contact in athletes with IT band pain, which we know requires greater time spent in pronation to bring the forefoot into contact with the ground.

Additionally, a common finding at the hip and knee in running athletes with IT band dysfunction is markedly greater peak and velocity internal rotation at the knee as well as increased total adduction compared to healthy athletes or healthy limbs.  Again, the anatomy of the IT band would dictate increased strain with adduction and IR of the knee during gait.  It appears as well that strength is correlated with iliotibial band problems in runners, and a six week program of specific muscle strengthening has shown promise in eliminating the pain associated with IT band problems.

A few general recommendations:

1.  Assess from the bottom up and correlate with problems.

2.  Mobilize the ankle into dorsiflexion to assist in the formation of subtalar stability.

3.  Ensure adequate strength of the hip abductors and external rotators to develop transverse plane stability at the knee.  Remember that the posterior gluteus medius and gluteus maximus aid in the posterior glide of the IT band and may reduce friction.

4.  Treat the quality of the tissues.  Remember that the TFL and anterior fibers of the gluteus medius are hip flexors and internal rotators that can become locked short and riddled with trigger points in runners and also have a direct influence on the IT band.  Additionally, one should ensure the function of the Windlass Mechanism is in place to be sure the hip flexors are not required more than necessary.

Best regards,

Carson Boddicker

Further Reading:

irnbaum, Siebert, and Pandorf. “Anatomical and bio- mechanical investigations of the iliotibial tract.” Surg Radiol Anat 26 (2004): 433-46. Print.