ITB Syndrome, Stretch or Strengthen?

In a previous life (well, 2 years ago actually, but let’s be honest that sounded way more dramatic), I was a Chartered Physiotherapist. I suppose technically, I still am. I graduated from Southampton University in 2008 with a degree in physiotherapy and spent 8 years working in both the NHS and private sector.

The knowledge I gained has come in handy on many occasions when inevitably, I get injured. After chatting to a friend who withdrew from the Bournemouth marathon last year due to ITB syndrome, it got me thinking. In my opinion, ITB syndrome is one of the most mis-treated injuries amongst runners. Despite being one of the most common.

What is the ITB?

The Iliotibial band, or ITB, is a thick band of fascia, a sort of connective tissue, expanding from your pelvis, down the outside of your thigh, towards your knee. It stabilises your knee when it is straight and also in a slightly bent position, and is therefore particularly pertinent to runners. Parts of your gluteal muscles insert into the top portion of your ITB.

In years gone by, it was thought that if you overused your ITB it became tight and rubbed on the bony prominence on the outside of your knee, causing pain. More recent studies however, have found that the ITB is firmly anchored along the thigh bone, making it hugely unlikely that this ‘friction syndrome’ was the case at all.

So what then, causes that horrible, sharp pain amongst so many runners?

It is now widely accepted amongst medical professionals that ITB syndrome is actually a compression issue. Brace yourself, here comes the technical bit! When your knee bends to about 30 degrees, your ITB is drawn inwards due to normal inward rotation of your shin bone. The problems occur when this inward rotation is too excessive. This is often because the gluteal muscles at the top of the ITB are weak, allowing your knee to drift inwards every time your foot strikes the floor when running.

This exaggerated action compresses the adipose (fatty) tissue beneath your ITB which is thought to contains lots of small nerves that detect pain. Evidence now suggests that this repeated compression is the source of pain, not your ITB itself. Ouch!

What does this mean for treating ITB syndrome?

Historically, treatment has included stretching, foam rolling and massage. Advice that is still regurgitated by many sources (cough….Google!) As far as I can see, there are two main problems with this. Firstly, we now know from cadaveric studies that the ITB is anchored to the thigh bone. Trying to stretch it would therefore be similar to nailing a straightened out bike tyre to a plank of wood. Then wondering why you couldn’t stretch it any more. Secondly, even when dangling substantial weights on the end of an ITB, it’s maximum stretch is thought to be around 2mm.  As this is far more force than you are likely to be able to generate by more conventional stretching methods, it hardly seems worth the effort, does it?

So if stretching doesn’t help, where does that leave us?

If you accept the compression theory of ITB syndrome, then the only logical treatment is to correct your bio-mechanical abnormalities. This means looking at the causes for the increase in shin rotation and correcting any hip weakness you may have. Particularly of your gluteal muscles and foot posture. I feel some bridging, clams and single leg squats coming on!

My advice…

  1. See a physiotherapist if you are developing what you think might be ITB syndrome. There may not be a quick fix like massage, but the quicker you get to the root of the problem and address it, the quicker you’ll be back. It might require some hard work, but on the plus side it may also save you £££££’s on futile weekly massages for the issue. Bonus!
  2. Make sure that as your mileage increases, so does your strength and conditioning. The demands of running are high, so your strength training needs to match that. One reason I take issue with a simple, non-weight bearing clam….but that’s for another time!!
  3. Stretching absolutely has a place for maintaining/developing muscle length, but as the ITB is not a muscle, it may well be time for a re-think.

And finally,

Don’t wait until you have problems before you start addressing a lack of strength training. Prevention is after all, the best cure!

I’m always on the look out for new, creative gluteal strengthening exercises so please share any that you’re currently loving.

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