Iliotibial Band Syndrome: It’s Not What You Think It Is

In the 1970s, a military doctor named James Renne would be the first to document cases of iliotibial band syndrome (ITBS). Back then and even to this day, many, including Renne himself, considered the syndrome to be caused by excessive “friction” of the iliotibial band over the bony outer side of the knee. The constant movement of a tight iliotibial band over bones in our knee from running was thought to lead to pain and inflammation eventually. However, with more contemporary investigations and research, there is now strong evidence to suspect that the iliotibial band simply impinges upon sensitive structures and that the band actually loosens during the disease process (Fairclough et al., 2006; Fairclough et al., 2007; Friede et al., 2020). Thus, common treatments like stretching in hopes of loosening the iliotibial band may be counterproductive and the rehabilitative focus should instead be towards strengthening and de-loading. In this article, let us explore what may be taking place underneath the hood and what we can do about it.

So what is actually going on with Iliotibial Band Syndrome?

While it was once thought that bones were directly underneath the iliotibial band, we now know that there are other structures in between the bones and the band itself. One of these structures includes a fat pad likely there to serve as cushioning. What is interesting about the fat pad in this context is that it has a very rich nerve supply which means it is very sensitive. It has been shown that while it may be impossible for the band to “flick” over any bones, it can compress any structures underneath, especially as your knee bends. This process is a more likely candidate for why runners encounter iliotibial band syndrome so frequently. If this is the case, why do many still believe in the former “friction” idea?

How did we get it wrong?

Beyond not being familiar with current research, the intuitiveness of the traditional friction theory is very attractive. Clients with ITBS would describe a “catch and release” sensation in their knee as they bent and straightened it continuously. Clinicians performing their assessments on patients with ITBS would feel a similar sensation when they put their hands over the patient’s knee as it moved. An overly tight iliotibial band was thought to exacerbate this repeated flicking as a looser band would not lead to such violent jerking or snapping of the band. While this all feels and looks like it would make sense, it is all likely an illusion.

Anatomically speaking, it is hard to imagine the iliotibial band snapping over any bones in our knee repeatedly. The band has several attachments in the knee including the area where the friction was hypothesized to occur. If the band is securely attached to the bone below, how could it possibly flick over said bone? Furthermore, the band is attached to a much broader sheet of tissue called the fascia lata which envelopes the thigh. The appearance of an isolated band is deceiving as it really just a more prominent portion of the fascia lata. Lastly, it was found that those with ITBS may actually have a looser iliotibial band compared to healthy people. It is still uncertain if the band is initially tight and then loosens as part of a bodily self-defence mechanism against injury or if the loosening itself causes all the knee pain and dysfunction. Regardless, those with ITBS are likely dealing with a loose iliotibial band rather than a tight one. After a period of rehabilitation, those that get better actually get tighter iliotibial bands.

How do we apply this information into our rehabilitation?

Perhaps the most important advice is a period of rest from running followed by a measured return to activity. A general rule would be to not attempt running until both walking and fast walking are pain-free. Running can be progressed by roughly 10% of mileage per week until goals are met. Hip muscle strengthening is another cornerstone for iliotibial band management as they are directly attached to the band itself and their strengthening has been shown to tighten the iliotibial band. Potential exercises may include lunges, clamshells, split squats or side-walking. During these exercises, we must prevent the knee from caving in, which may exacerbate pain via fat pad impingement. Stretching and foam rolling may be performed if they provide pain relief but they should not be done in the hopes of elongating or loosening the iliotibial band. These modes of treatment are helpful in the same way that massages can be relieving but the effects are often transient if any and the root cause is not addressed. Lastly, trained clinicians like our team of physiotherapists can utilise numerous manual therapy techniques and modalities like extracorporeal shockwave therapy which may also be helpful in managing ITBS.

If you are experiencing Iliotibial Band Syndrome and would like to seek physiotherapy treatment, contact us to book an appointment with our team of physiotherapists.

References

• Fairclough, J., Hayashi, K., Toumi, H., Lyons, K., Bydder, G., Phillips, N., … & Benjamin, M. (2006). The Functional Anatomy of The Iliotibial Band During Flexion and Extension of The Knee: Implications for Understanding Iliotibial Band Syndrome. Journal of Anatomy, 208(3), 309-316. https://doi.org/10.1111/j.1469-7580.2006.00531.x.
• Fairclough, J., Hayashi, K., Toumi, H., Lyons, K., Bydder, G., Phillips, N., Best, T. M., & Benjamin, M. (2007). Is Iliotibial Band Syndrome Really a Friction Syndrome? Journal of Science and Medicine in Sport, 10(2), 74–78. https://doi.org/10.1016/j.jsams.2006.05.017.
• Friede, M. C., Klauser, A., Fink, C., & Csapo, R. (2020). Stiffness of The Iliotibial Band and Associated Muscles in Runner’s Knee: Assessing The Effects of Physiotherapy Through Ultrasound Shear Wave Elastography. Physical Therapy in Sport, 45, 126-134. https://doi.org/10.1016/j.ptsp.2020.06.015.