Iliotibial Band Syndrome
Iliotibial Band Syndrome (ITBS) is a running injury where athletes commonly experience sharp pain on the outside of the knee. Previously, this injury was believed to be caused by friction of the ITB on its attachment site at the knee, hence being called ‘ITB friction syndrome’. However, in recent years this injury has been found to be due less to friction, but more by compression of the tissue and the fat-pad lying beneath the ITB attachment point. Although most common in runners, ITB syndrome can also present from cycling, with the cause of the injury being largely similar between the two.
The ITB is a thin but highly rigid piece of tissue that runs from the Tensor Fasciae Latae (TFL) muscle at the hip, through to its bony attachment on the outside of the knee. It provides support to the knee when in the single leg stance phase of both walking and running – this is the point from initial foot contact until the foot then leaves the ground. It works alongside the muscles of the hip to perform active movement and also helps prevent torsional and twisting forces within the knee joint.
Commonly referred to as ‘runner’s knee’, ITBS is estimated to account for up to 22% of all lower limb injuries in runners. Athletes with ITBS commonly experience sharp pain on the outside of the knee (upon the bony attachment of the ITB). Its gradual type onset means that lingering knee pain may be felt in the early stages of injury before it advances to the point of stopping the athlete mid-way through training or competition. Pain may come without warning throughout a run and/or ride and may even bring the athlete to a sudden halt, with prolonged pain when attempting to continue. Aside from pain with activities such as running and/or cycling, the athlete will have tenderness when pressure is applied to the attachment at the outside of the knee.
Both running and cycling rely on activation and strength in the hip musculature to ensure hip stability is upheld during each activity, and when assessing the primary cause of ITBS it is often the hip that requires the most attention. Any deficits in the strength and activation of the hip muscles, as well as the limited range due to joint stiffness, may put unnecessary stress on the ITB leading to overuse.
The gluteus medius and gluteus maximus are two import muscles for the stability of the hip when running and cycling. If these muscles are prone to fatigue or not engaging effectively, often the TFL muscle will activate to compensate for weakness in the glutes. This can then increase the load of the ITB as it connects to the muscle fibres from the TFL.
Biomechanics when running and poor running technique is a common cause of ITBS. Running technique should be properly evaluated to identify any movement deficiencies, and more specifically looking at any increased hip sway when running, most commonly due to weakness and/or inactive gluteal muscles and their inability to provide sufficient hip stability.
For cyclists, having a professional bike fit can help to ensure correct positioning and technique is being used, with the correct load being placed on appropriate structures. Cyclists also require adequate glute strength on the bike and ensuring that the glutes are properly engaged throughout the pedalling motion can help reduce any unnecessary load on the ITB.
Hip strengthening should form part of every triathletes training regardless of injury but is of greater importance with injuries of this nature. In the presence of ITBS, running and/or cycling loads should be reduced as to minimise any further aggravation of the injury and appropriate gym-based exercise should also take place. When beginning this the ‘isolate then integrate’ method is a simple and effective way to structure strength rehab. For ITBS this would begin by focusing on hip activation exercises to improve the responsiveness of the hip muscles and their ability to contract when required. Once these muscles are more easily recruited during activity, the athlete would need to integrate this into more meaningful activity, that being more specific to the sport and movements needing to be performed. As the difficulty of the exercises progress, more dynamic exercises will need to be done. The focus of each exercise should be keeping the hips level without allowing the pelvis to drop to either side, fulfilling their role of stabilising the hip.
Coaches, trainers and physiotherapists are well equipped with exercise prescription skills and knowledge.
A detailed physical assessment may help identify the areas needed for improvement, and ensure the most suitable exercises are given to enhance recovery and provide future prevention of the injury.