Iliotibial Band Syndrome (ITBS) is a common ailment for many recreational and professional runners.  It has an easily recognizable pain pattern that begins at the crest of the hip and descends to the outside of the knee. Although extremely familiar to most runners, it is one of the most misunderstood running related injuries.

What is the Iliotibial Band?

The Iliotibial band (IT Band) is really just a long tendon of the tensor fascia latae and the gluteus medius and maximus.  This muscle attaches at the top point of hip and spans about 3-4 inches, before transitioning into the IT Band further down the leg.  Ultimately, the IT Band crosses the outside of the knee and attaches to the tibia. Since the IT Band crosses two joints, it can be directly affected by any of the abnormal tissues that surround the knee or the hip.  Flexing the knee between 10-15 degrees causes the IT band to maximally tense and relatively migrate backwards which may cause a rubbing irritation on the outside of your knee at the femur’s lateral epicondyle.

Why Avoid Passive Treatments?

Runners are incredibly smart and love to research treatment options. Unfortunately, most online and word of mouth approaches tend to lead runners to passive treatments like icing, ibuprofen/naproxen, foam rolling, generic glute work, or taking time off in order to assuage their symptoms.  These options may ease the pain, but will not, however, truly address the underlying cause.  It is crucial to look both up and down the kinetic chain, for example, the pelvis and ankle,  to find the culprit of ITBS. Although foot issues are often to blame, the hip stabilizers are typically the cause of ITBS.  

What Are The Real Causes of ITBS?

Enter the knee’s friends - the gluteus maximus and the gluteus medius are the stars when it comes to hip and knee stability.  Abnormal firing patterns in these muscles during dynamic loading activities, like running, can have deleterious effects down the kinetic chain.   Normally, the forces created while running would primarily be absorbed by and transferred to the glutes. With insufficient glute recruitment, however, those forces create uncontrolled motion at the hip and knee. Less than ideal knee and hip biomechanics results in abnormal tensioning or pinching of the IT Band.  When this happens, runners often complain of pain along the outside of the knee, and extreme tightness along the lateral quad. ITBS likes to rear its ugly head when runners increase intensity and especially as core and hip mobility and strength training are given the backseat.

How Can I Fix it?

So how do you control these aberrant movements and prevent or treat ITBS?  The fix is a rehab plan that consists of individualized hip and core stability movements and exercises.  Although the foam roller may be effective for massage purposes, the IT Band cannot be lengthened substantially which means foam rolling is an ineffective strategy to stretch the IT Band. Foam rolling may feel good to some runners, but it is not sufficient alone in treating ITBS.

To help with ITBS, consider trying the exercises shown below.   These movements specifically address multidimensional hip and core stability. If you do not notice improvements quickly, visit www.forefrontpllc.com/location and schedule a personalized functional movement examination by one of our physical therapy doctors.  

Remember to take advantage of our referral reward promotion right now!  If you refer someone to Forefront Physical Therapy you are rewarded with a $10 Amazon Gift Card! Check out more details about our Referral Reward Program.

Click here and here see studies that examined how the IT Band cannot be truly lengthened by stretching or foam rolling.

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Dr. Dan Benson, DPT, OCS, FAFS

Forefront Physical Therapy
Belltown & South Lake Union
2720 4th Ave #115
Seattle, WA 98121

An Overview:

Ankle sprains often result in a loss of foot pronation which in turn disrupts the hip biomechanics necessary for the loading and unloading phases of activities like walking.  Because of the disruption of hip biomechanics, the low back must compensate for a loss of normal shock absorption at the hip and a common side-effect is low back pain.  Quickly restoring normal foot mechanics is essential for pain free walking and other activities. 

The detailed version:

Most ankle sprains are the result of an inversion and plantar flexion movement to an extreme, uncontrolled range.  Typically, the anterior talofibular ligament is overstretched and the result is pain and inflammation.  It should be noted that if you cannot walk immediately after the ankle injury or meet any of the other Ottawa ankle rules criteria, it is important to visit a doctor who can do an x-ray. 

After the typical inversion ankle sprain, foot pronation is lost – specifically, subtalar joint eversion combined with adduction and plantarflexion.  Foot pronation allows the tibia to internally rotate which then allows the femur to internally rotate.  The result is hip internal rotation, adduction and flexion which are the 3-planes of motion that maximally stretch the glutes and provide those muscles with the optimal ability to help decelerate gravity and reduce shock absorption at foot strike. 

The loss of subtalar joint eversion means there will be less ability for the hip to accept ground reaction forces.  Instead of the low back experiencing controlled and cushioned motion, it will experience excessive stress.  The result is low back pain which may manifest on either side.

Sometimes, the fibular head may shift forward as a result of the sprain and if this occurs, it is essential that functional manual reaction be used to mobilize the foot into pronation while slowing down the fibular head’s forward motion in space.  The sooner normal foot pronation and fibular head mechanics are regained, the sooner the ankle will feel better and the normal chain reaction biomechanics will be restored – this will result in an ankle that feels better faster and a back that will stay healthy.

Quickly and safely restore normal ankle motion after a typical inversion ankle sprain: 

Dan Benson, DPT, OCS, FAFS, CAFS
CEO Forefront Physical Therapy
Nike Golf Performance Specialist

Forefront Physical Therapy
South Lake Union
2720 4th Ave Ste 115
Seattle, WA 98121

As explained in Part 1, the track workout warm up starts with an easy 2 lap jog followed by running modification drills.  Immediately following those drills are a series of lunges that are modified by changing where the arms reach during each lunge.  We typically perform 10 lunges (5 lunges with each leg) with each of the 6 different arm reaches. 


Lunges with 3D Arm Reaches


Forward Lunges with Arms Reaching at Overhead

• What the Runner Feels:  a big stretch to the front of the thigh of the trailing leg.
• What the Movement Expert Says:  reaching both arms at overhead while you lunge will reduce the amount of anterior tilting of the pelvis – this means that the hip of the trailing leg will experience greater extension which will create a significant stretch to the hip flexor and quad in the sagittal plane.

Forward Lunges with Arms Reaching toward the Ground 

• What the Runner Feels:  a big stretch to the back of the thigh of the leading leg.
• What the Movement Expert Says:  reaching both arms toward the ground while you lunge will increase the rate and amount of anterior tilting of the pelvis – this will create increased hip flexion of the leading leg which will result in increased stretch to the hamstrings in the sagittal plane.

Forward Lunges with Arms Reaching at Overhead to the Same Side of the Lunging Leg

• What the Runner Feels:  the leading knee diving medially.
• What the Movement Expert Says:  the overhead reach to the same side as the lunging leg will shift the center of gravity medially which will limit the leading hip’s ability to adduct – to compensate, the leading knee will abduct while the leading foot will pronate.  Both these motions occur in an effort to load the butt muscles of the leading leg.

Forward Lunges with Arms Reaching at Overhead to the Opposite Side of the Lunging Leg

• What the Runner Feels:  the side of the leading hip stretching.
• What the Movement Expert Says:  the overhead reach to the opposite side of the lunge leg will shift the center of gravity laterally which will result in increased adduction of the leading hip.  This will create a large stretch to the adductors of the trailing leg and a large stretch to the abductors of the leading hip.

Forward Lunges with Arms Reaching Same Side Rotational at Shoulder Height

• What the Runner Feels:  increased butt muscle activation of the leading leg.
• What the Movement Expert Says:  the same side rotation reach will increase the internal rotation of the leading hip which will help load the butt muscles of the leading leg.

Forward Lunges with Arms Reaching Opposite Side Rotational at Shoulder Height

• What the Runner Feels:  a stretch to the hamstrings of the leading leg.
• What the Movement Expert Says:  the opposite side rotational reach will increase the transverse plane load to the medial hamstrings and the adductors of the leading leg.  The reach will also increase the transverse plane load to the trailing hip – this will result in increased hip internal rotation which will improve the load to the hip flexors of the trailing hip.

All professional athletes go through a specific, well-planned warm up before any athletic activity.  Creating new habits where running modification drills and lunges become an integral part of your running experience will help you maintain a healthy body while improving your speed and ability to be successful in the sport you love.

As mentioned in the previous post, all joints and muscles load and unload 3-dimensionally during any activity – this allows your muscles to decelerate and or accelerate motion in one to three planes of motion.  Adjusting motion and exercise patterns is critical for maintaining mobility with strength and keeping your body healthy.  The overarching purpose of these movements is to increase motion while at the same time teaching your body to control new motion.  Waking up as many muscle groups and nerve pathways (or to be more precise, proprioceptors) as possible before running or any activity is always crucial and this is often best accomplished by introducing variable movements.


Dan Benson, DPT, OCS, FAFS, GPS, CAFS, FMR

CEO Forefront Physical Therapy
Doctor of Physical Therapy
Orthopedic Certified Specialist
Fellow of Applied Functional Science from the Gray Institute
Nike Golf Performance Specialist
Certified in Applied Functional Science
Certified in Functional Manual Reaction

www.forefrontpllc.com

This will be a 2 part series designed to explain the “why” behind the different exercises I guide the Green Lake track workout group through every Monday evening. 

We always start with 2 laps of slow jogging to get the blood flowing.  At lap 3, on the straight sections, we begin the running drills.  Those technique modifications include running with feet normal width apart with toes turned in and then toes turned out.  The next set of alterations move feet further apart than normal with toes neutral, turned in and turned out.  And the final set involves the feet coming across midline with toes neutral, turned in and turned out.  To explain the effects in detail, I will limit the discussion to one variable at a time. 

Modifications Introduced While Running

Toes Turned In

• What the Runner Feels:  increased activation of butt muscles during the initial loading phase (foot strike) and increased stretch to hip flexors during late stance phase.
  

• What the Movement Expert Says:  there is decreased pronation due to increased hip internal rotation during the loading phase and increased supination and hip internal rotation during the late stance phase.  There is also increased thoracic spine rotation which means increased core loading. 
  

Toes Turned Out

• What the Runner Feels:  decreased activation of butt muscles during the loading phase and decreased activation of hip flexors during late stance phase.
  

• What the Movement Expert Says:  there is increased pronation and decreased ability for the gluteus muscles to activate during loading phase (because pronation has improved, the hip will internally rotate, just not as far as usual) and decreased supination during the late stance phase.  There is decreased thoracic spine rotation which means less core (front and back) ability to stretch and activate to help with all phases of the running cycle – this teaches the body to use and control motion without its typical resources.
  

Feet Wide

• What the Runner Feels:  decreased butt muscle activation during loading phase and variable hip flexor loading during late stance phase.
  

• What the Movement Expert Says:  there is increased pronation during loading phase and decreased supination during late stance phase.  Despite the increased pronation, with your feet wide, it is harder to recruit the gluteus muscles due to a lack of hip adduction during loading phase; the hip flexor likely loses much of the internal rotation pre-load during late stance phase but receives a better frontal plane load relative to running. There is decreased core loading due to decreased thoracic spine rotation.
  

Feet Across Midline

• What the Runner Feels:  increased butt muscle activation during loading phase and less ideal hip flexor loading during late stance phase.
  

• What the Movement Expert Says:  there is decreased pronation during loading phase, and increased supination during late stance phase.  This produces improved gluteus muscle loading due to improved hip adduction during loading phase; there is decreased frontal plane load to hip flexors during late stance phase but increased hip internal rotation.  At the mid back there is improved core loading due to increased pelvis tilt and rotation creating increased thoracic spine Type I mechanics (opposite side rotation and side bending).
  

All joints and muscles load and unload 3-dimensionally during any activity – this allows your muscles to decelerate and or accelerate motion in one to three planes of motion.  Adjusting motion and exercise patterns is critical for maintaining mobility with strength and keeping your body healthy. 

There will be little difference if you are a heel, midfoot or forefoot striker with these drills.  The overarching purpose of these movements is to increase motion while at the same time teaching your body to control new motion.  Waking up as many muscle groups and nerve pathways (or to be more precise, proprioceptors) as possible before running or any activity is always crucial and this is often best accomplished by introducing variable movements.


Next Segment:  Part 2 – Lunges with 3D Arm Reaches 


Dan Benson, DPT, OCS, FAFS, GPS, CAFS, FMR

CEO Forefront Physical Therapy
Doctor of Physical Therapy
Orthopedic Certified Specialist
Fellow of Applied Functional Science from the Gray Institute
Nike Golf Performance Specialist
Certified in Applied Functional Science
Certified in Functional Manual Reaction

www.forefrontpllc.com