ITB Friction Syndrome


With the winter running season approaching it’s time to look at a very common injury that affects runners of various shapes, sizes, ages and abilities – ITB friction syndrome. It usually starts as a dull ache on the outside of the knee but can progress to an extremely sharp and disabling pain. Let’s run the usual analysis.


What is it and how does it happen?

The ITB (aka ilio-tibial band) is a thick band of fascia connective tissue that runs down the outside of your thigh from the pelvis to the knee. As your knee bends and straightens, the ITB passes across a bony lump on the outside of the knee. The thicker and tighter your ITB and the more times it rubs over the bony lump, the more likely it is that you will get friction-inspired inflammation and pain.

Steady paced jogging creates more problems than speed intervals or sprinting. Downhills or running on a sideways-sloping surface (e.g. the edge of a road) also notoriously provoke ITB friction syndrome. There is no single biomechanical problem that causes it, so just about any runner is susceptible. Inadequate stretching of all the leg muscles and insufficient gluteal (buttock) muscle strength and endurance are common findings in our assessment. We normally find tender myofascial trigger points or knots in the muscles attaching to the ITB which contribute to the tension on the band. Usually this injury gets worse if you continue to run, and will then take longer to settle down.

How do you treat it?

The management of ITB friction syndrome can be divided into a number of areas:

1. The anti-inflammatory treatment for the symptoms at the knee includes ice packs, electrotherapy machines, anti-inflammatory medications/gels, and in severe or prolonged cases a corticosteroid (cortisone) injection is recommended.

2. The mechanical de-tensioning treatment of the ITB involves deep tissue massage, suction cup releases and stretching. You may have heard that the massage and suction cups really hurt and that’s pretty much on the money, at least initially. At home you can use a short, firm foam roller (available to purchase from your physio) to partly simulate the massage, perhaps 10-15 minutes every second day. It is important to maintain or improve overall leg flexibility through daily stretching of all major muscle groups. There are a variety of stretching positions for various parts of the ITB which are difficult to explain and draw but a quick web search found this link which has photos of some of my faves:

3. The exercise rehab treatment of ITB syndrome is to improve the strength and endurance of the gluteal muscles that maintain the position of your pelvis and affected leg when it’s in contact with the ground. Specific instruction by your physio is recommended, and we often use the EMG biofeedback machine to check that you are performing these exercises correctly. Some examples would include ‘clam shells’, single leg bridging, pelvis tilt control in standing, single leg balancing drills, step exercises and squats. The progression through the exercises is dependent on them not causing any pain.

4. The training modification program is dependent on the severity of the case and the outcome of running gait analysis. We would start as far down the ITB rehab activity progression (listed below) as we could, then gradually progress as symptoms allow. This is a good time to make any technique improvements that your coach or physio suggest.

ITB Rehab Activity Progression

– No activity

– Swimming with pool bouy (no kick)

– Swimming with kick; deep water running

– Cycling low gear, easy intensity, no hills; flat walks

– Cycling moderate gears, intensity and hills; walks including hills

– Cycling no restrictions; walks including 50-100m run intervals at fast pace on flat grass surface

– Longer run interval sessions and short jogs (e.g. 1-3km) on flat grass

– Moderate jogs (3-8km) on flat grass and short jogs including uphills but walking downhill

– Long jogs (8km +) on flat grass and moderate jogs including hills (up and down)

– Running no restrictions

5. A podiatry assessment is often warranted to check if your feet or shoes are likely to be contributing to your ITB syndrome. Orthotics can work wonders in some ITB cases.

6. Prevention of recurrence is a big issue for ITB friction syndrome. I recommend that my patients continue with the ice packs, mechanical de-tensioning and exercise rehab treatments for some time after their symptoms resolve. Some runners will need to continue to do these treatments (mostly by themselves) in order to prevent the injury returning. In any case you should be more aware of the problem developing and commence treatment promptly if mild symptoms recur.

The Take Home Message

ITB friction syndrome is an extremely common overuse running injury that can affect just about any runner. There is a large range of treatment options to address the symptoms and causes of the injury. See your physio for prompt treatment before the symptoms become severe!

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