IT Band Syndrome or Iliotibial Band Friction Syndrome (ITBS or ITBFS)

IT Band Syndrome (ITBS) or Iliotibial Band Friction Syndrome (ITBFS) is a condition which results when a ligament extending from outside of the pelvic bone extending to the outside of the tibia (iliotibial band) becomes so tight and as a result it starts rubbing against the outer part of the patients’ femur. Susceptibility is high in long distance runners.

IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) is a knee injury that is common, and running weight lifting (particularly squats), hiking and cycling is generally attributed to it occurrence.

Lateral knee pain in runners is commonly caused by IT band syndrome (ITBS) or iliotibial band friction syndrome.^[1]

Runner’s knee might be referring to a couple of overuse injuries that involve pain at the cap of the knee (patella) like: Chondromalacia patellae, Patellofemoral pain syndrome, plica syndrome or IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS).

IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) is the major cause of lateral knee pain in runners. Inflammation or tightening of the ligaments running down the outside of the thigh, starting from the hip up to the shin, called iltibial band, leads to IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS). The attachment and the stability of the joint are achieved through attaching IT band. Pain will occur during running if the band is not properly working knee movement resulting when running.

Any activity with potential of turning the leg inward repeatedly gives rise to IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS). It includes wearing of old shoes, running on a banked surface or downhill, using the same direction to run tracks and workouts or in other terms running many miles. Beginners and seasoned runners are more afflicted with these pains. Rubbing between an ilitobial band and the knee bone can occur due to because it narrows when it comes near the knee. Inflammation occurs as a result. Women are more vulnerable to IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) possibly the reason is the hips of women tilt in a manner that causes the turning of knees.

• Congenitally tight or wide IT band.
• Hip muscles which are weak.
• Presence of trigger points in the IT band and gluteal muscles.
• Over pronation and overuse.
• Extreme running.
• Discrepancy in the leg length.^[2]

Majority of the runners often mistake IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) to a knee injury because the symptoms that are notable easily are pain and swelling on the outer part of the knee. You will have to keep your knee in a 45 degree position in order for you to know. The outside of your knee will be painful if you have IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS).

General tenderness will be felt through physical examination at the iliotibial band insertion section in the knee joint, and tender points that are specific will be felt. This is at the lateral femoral condyle, the position where bursa is located. Imbalance or weakness of the muscles in front of the thigh extending to the knee (quadriceps muscles) and hamstring muscle which is located at the back of the thigh which enables the knee to flex may be detected in the examination.

Tightening the iliotibial band may occur. While the patient will be taken through various stretches, the doctor will be able to determine its flexibility. The flexibility of iliotibial muscle, the gluteal muscle, and fascia latae, can be accessed through two test maneuvers namely, ober test and Thomas test.

• Pain in the external area of the knee.
• Stiffness felt in the iliotibial band.
• Increased pain during activities such as running, cycling.
• Flexion or extension of the knee causes pain and pain increases when the area of the knee over the tender part is pressed.
• Decrease in strength during hip abduction.
• There may be painful trigger points in the gluteal area.^[3]

Simple training mistakes made by individuals could lead to IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS).

The common mistakes in training that can give rise to IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) are described below:

• Lack of flexibility or strength can lead to IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS). Tightening of the IT band can result if your muscles found in the thigh, known as hip adductors, turns out to be weak.
• Avoiding warm-up exercise can put you at a risk for IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS). Warming up for at least 5-10 prior to intense build up exercise will benefit the soft tissues and the muscle despite being tempting to embark on workout directly.
• Too fast ramping up training can also put you at risk for IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS). It is not good always to be under ambitious training schedule. In order for athletes to avoid other injuries and ITBS, they are advised to add intensity and length at a slow pace during workouts for a couple of weeks and months.
• Wearing improper footwear can cause IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS). The landing design of the foot on the ground affects the foot and ankle muscles and also the hip, the knee, other muscles and other inclusive soft tissues supporting the joints. IT band pain can be prevented or reduced with improved biomechanics achieved through proper footwear.
• Running on rough surfaces. A terrain or a surface which increase the risk of runners developing IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) is:
  1. Concrete surfaces
  2. Hilly regions
  3. Banked or uneven for example slanted road sides down towards the curb.^[4]
• Poor cycling style. IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) risks is increased by cyclist if:
  1. The seat of the bike is too high which forces too much extension of the leg which might trigger IT band issues.
  2. Too much hardness of the gear which forces the leg to strain harder with less RPMs.
  3. Poor adjustment of the toe slips and the pedals for the cyclist properly.

Whereas cyclist and runners have more susceptibility to IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) pain, any athlete engaging in knee motion repeatedly can be affected too. Other examples of athletes with the propensity of experiencing IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) are weight-lifters, soccer players, basketball players and speed-walkers.

Misalignment of the joints and biomechanical problems can be a predisposition to an individual having a training program that is great. Predisposed IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) individuals include:

• People bowing legs.
• Different length of the legs.
• Male under 34 year of age are vulnerable.

IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) is often diagnosed basing on the information from the patient regarding symptoms. The progress of the pain that worsens when the knee touches the ground will be described by the patient. It is helpful to have physical examination due to the location of the pain can be palpated often with swelling and tenderness which occur at the femoral epicondyle at the position of the bursa or sac.

The doctor might look into the discrepancy regarding the length of the leg, the tightness of the back and the leg and muscle imbalance. Examination is normally to check tenderness outside the thigh where the hip and knee joints just above the knee.

Other causes of the outer knee pain are usually detected through a physical examination in full of the legs and the low back which include the hips, ankle and knees.

Diagnosis does not usually require plain X-ray, but MRI use might be recommended in looking inflammation around and below the iliotibial band. Other causes of knee pain can also be excluded by MRI. Tendon inflammation, sprained cartilage, lateral collateral ligament sprain and lateral meniscus (torn cartilage) are some of the examples.^[5]

General summary of the treatment involved in IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS):

• Conservative treatment such as rest and avoiding activities which cause pain, e.g. running, cycling is the best approach to treat IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS)
• Ice packs helps reduce inflammation associated with IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS).
• Stretching the Iliotibial band.
• Massaging the tender area helps in reducing ITB tightness.
• Anti-inflammatory drugs such as NSAID’s (ibuprofen) can help in treating the pain and inflammation associated with IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS).
• Myofascial release techniques and dry-needling techniques are also effective.
• Electrotherapeutic treatment techniques like TENS or ultrasound help in reducing the pain and inflammation.
• Corticosteroid injection can be given into the area of irritation for pain relief from IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS).
• Consulting a sports injury specialist.

Apart from controlling pain using anti-inflammatory medications, a stepwise approach regarding the treatment is recommended.

Many IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) patients can be treated viably though physical therapy (PT). Biochemical that underlies the cause of inflammation of the IT band can be passed through running style and technique as wished by the therapist. Muscles stretch assessment, flexibility and gait analysis may be included.

• Any abnormality or imbalance due to IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) can be corrected through the help of orthotic shoe or proper shoe recommended by a physical therapist.
• Tight structures can be loosened through specific teachings from the physical therapist.
• What may be considered when treating an injury that is acute, ionopheresis which is the use of an electric charge when delivering medication via the skin, instead of ultrasound or phonopheresis which is an ultrasound technique used in propelling anti-inflammatory.

If physical therapy (PT), rest and ice does not solve the inflammation associated with IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS), the doctor, may take into consideration an injection of corticosteroid in the area inflamed.

Surgery exists as an option on failure of other modes. The scarring of the area surrounding the IT band may be broken down by the use of an arthroscope by an orthopedic surgeon. Inflammation and potential inflammation cause by the band when crossing the femoral condoyle can be decreased through lengthening of the band.

Just like any overuse injury, with the resolution of the first episode, discerning of the cause of the inflammation is very important for the patient to do. In order to prevent the recurrence of IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) symptoms, recommendations from the physical therapist (PT) about the training techniques, orthotics necessity, proper stretching and footwear options should be considered. The aim of the patient, in essence, is returning to his/ her level state before the injury.

The following are steps that can be taken to prevent IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS):

• Relax for a few days or decrease your mileage if pain has occurred on the outer part of your knee is important.
• Before running warm up for a quarter to half a mile.
• Ensure the outside sole of your shoe are not worn out. Replace them if they are.
• Run in the flat part of the road usually the middle. Find roads that are visible well and have little traffic.
• Avoid concrete surface when running.
• Repeatedly change direction on track run.
• See if you need orthotics by scheduling an evaluation with a podiatrist.

Treatment initially aimed for majority of overuse injuries never change: resting, icing elevation and anti-inflammatory medication. Aggressive activities often elevates the aggrieves of the symptoms such as running; cross-training and other alternatives like swimming or bicycling can be attempted as IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) is resolving.^[6]

Knee pain in runners or cyclers is caused by mainly by IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS). In order to strengthen the affected area and reduce inflammation, this three stage treatment can be used.

Inflammation and Pain Reduction: Reduction of pain is the main aim of the initial phase and the increment of IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) mobilization. Ice, rest topical anti-inflammatory and NSAIDS at this phase, are all effective. A corticosteroid injection occasionally helps, while bearing in mind the fact that the injection cannot cure the injury but only for pain reduction and enabling the patient to move to the next phase.

Stretching and Massage: Uses of deep-tissue massage progresses treatment which is ultimately necessary prior to moving to strengthening. Frequent massage is recommended by physical therapists: daily for elites and thrice weekly for recreational runners. If it is expensive to have a certified therapist or you do not have time to go, use a form roller viable for self therapy. Start rolling from the knee up to the hip. Engage in cross training for fitness maintenance which does not aggravate your condition. In case you are hurting try another alternative. Continue with deep tissue massage while stretching when the pain has subsided.

What occurs during these below mentioned stretching exercises is that pain may be felt at the upper nearing the knee instead of down where pain had been initially experienced; this is normal.

1. Stretching Exercises for IT Band Syndrome (ITBS) or Iliotibial Band Friction Syndrome (ITBFS)

   In the first stretching exercise for IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS), pull the foot behind your buttocks. Cross the leg that is not injured and push it down, and hold it for 30 seconds.

2. Stretching Exercises for IT Band Syndrome (ITBS) or Iliotibial Band Friction Syndrome (ITBFS)

   In the 2nd stretching exercise for IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) lean towards the side of uninjured leg while you have crossed the injured leg behind. When the hands is over the head is the best position of performing this stretch, making a ”bow” emanating from the ankle to the hand in the side that injured.

3. Stretching Exercises for IT Band Syndrome (ITBS) or Iliotibial Band Friction Syndrome (ITBFS)

   In the third stretching exercise for IT band syndrome (ITBS) or Iliotibial Band Friction Syndrome (ITBFS), cross the uninjured leg under the injured leg and pull your leg close to the chest as you possibly can.

1. Strengthening Exercises for IT Band Syndrome (ITBS) or Iliotibial Band Friction Syndrome (ITBFS)

   IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) stretch lengthening exercise that is most effective is stretching it outer side of the leg and across the hip. Lean toward the leg that is uninjured while you have crossed the injured leg at the back. Create a bow shape by stretching with your hands over the head first. Touch the ankle at the inside of the bow after bowing from the ankle to the hand while the injured ITB is outside. Below the right leg of the runner is undergoing stretching. Repeat this position 10 times and do each for 15 seconds each. Three sets are enough daily.

2. Strengthening Exercises for IT Band Syndrome (ITBS) or Iliotibial Band Friction Syndrome (ITBFS)

   Use a resistance band when beginning to use clamshell for IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS). Emphasize on being in good form while performing the exercise slowly. Each leg should have three repetitive sets while building up. As this exercise is becoming easier and in the process the leg is becoming pain-free, you can shift to strengthening that is more advanced.

3. Strengthening Exercises for IT Band Syndrome (ITBS) or Iliotibial Band Friction Syndrome (ITBFS)

   Side Leg lift exercise is a challenging strengthening exercise for it band syndrome (ITBS) or Iliotibial band friction syndrome (ITBFS). While you lay on your side, raise the leg on top straight up, and the restore the position in that manner, moving it forward and returning to the position you started. Form is important. Ensure that you achieve a straight line starting from the shoulder to the ankle but the top will be in front slightly. (Don’t allow backward rotation of the top hip). Slowly perform the sequence while pointing the toe down. Make three sets that you have repeated trice in each leg.

4. Strengthening Exercises for IT Band Syndrome (ITBS) or Iliotibial Band Friction Syndrome (ITBFS)

   Single-Leg squats can help in IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS). Use one foot to balance after which you bend the knee to lower the torso a quarter ways to the ground. Mimic running form when you have fully known straight quarter squat, because it is a more challenging exercise. You will have to extend the unsupported leg and bring it in a manner to that lift the knee in your front. Further ultimate move is touching the ground-while you forward lean- in front of you. Use a twisting motion to move diagonally up and down in a soccer ball manner, while you have stood on you right foot, starting with the lower left to the upper part of the right and finally side to side. Repeating the left foot, move the ball stating from lower right up to the upper left.

5. Strengthening Exercises for IT Band Syndrome (ITBS) or Iliotibial Band Friction Syndrome (ITBFS)

   Hip Hikes exercises are the final exercise in IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS). The abductors are worked by eccentric strengthening through the same manner of functioning when running, when strong enough. Stand on the stairs on one foot and raise the other through lifting the hip on the same side while being cautious when standing straight in a position that is upright. Stay upright as you lower your hip to the range you can reach at the bottom. Buildup 3 sets while performing and repeat it 10 times on each side.^[7]

It can take duration of weeks or months for someone to fully engage in activities without pain despite the fact that most IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) patients recover. Optimal results demands patience.

Prevention of IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) is achievable through the comprehension of important symmetry of the body. Symptoms can occur when activities has the symmetry.

Turning in the toes while pedaling exposes bicyclist to IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS) risk, and abnormal stretching of iliotibial band will result at the knee position. Development of symptoms can be minimized by awareness of pedaling technique.

Stretching of other structures and the muscles of the body is important in preventing musculoskeletal injuries which includes IT band syndrome (ITBS) or iliotibial band friction syndrome (ITBFS). Below are tips on when to resume cycling or running:

• Prior to running do warm up. Walking to easy gradual jogging is the criteria
• Buy shoes that are professionally fitting. Stability or motion-control shoe may help
• Replace your shoe often in case of wear and tear detection
• Avoid cambered roads and run on level surfaces. IT band injury can be contributed by a slanted road.
• Avoid running from exceptional hard surfaces or concrete
• If you are running on a track try to change direction by running in the lanes at the outer part to allow for a turn which is wider.
• Do not exceed 10% every week when you are increasing mileage and stick to it.
• Vary training activities like swimming if you can.
• Do not stop prescribed stretching and strengthening exercises.

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