Through Melbourne’s rolling lockdowns with gyms and training studios often closed, more and more people have turned to running to keep active and get outside (mask-less). This new habit has been kept up between lockdowns and as such, physiotherapists and sports physicians have been seeing more running-related injuries than ever before. This blog post will discuss the most common cause of lateral knee pain in runners, iliotibial band (ITB) pain syndrome.
What is the ITB?
The ITB is a thick layer of fibrous fascia that develops from two muscles, gluteus maximus and tensor fascia lata (TFL). Both of these muscles originate from the pelvis. The ITB runs down the lateral (outside) side of the thigh, crossing the knee joint and inserting onto the lateral tibia.
The ITB is important in lower extremity locomotion and contributes to lateral knee stabilization when running. It is a unique structure as it can contribute to both knee flexion and extension, depending on knee flexion angle.
What causes ITB pain syndrome?
ITB pain syndrome was originally thought to be a friction-related injury. The pain was thought to be generated by the ITB rubbing as it crosses the lateral femoral condyle (just above the lateral aspect of the knee). More recent research has proposed an alternate mechanism of compression rather than friction. The current evidence suggests that ITB pain syndrome is caused by compression of highly innervated (and thus pain sensitive) fat between the ITB and the lateral femoral condyle bone.
The ITB essentially squashes the innervated fat onto the lateral femoral condyle. Thus the terminology changed from ITB friction syndrome to ITB pain syndrome.
What are the symptoms of ITB pain syndrome?
The most common symptom of ITB pain syndrome is vague lateral knee pain that occurs with running. It can have a warm-up effect when mild but when severe it can progress to the point where you have to stop running. A post-run lateral knee ache is common. Pain on palpation at the point where the ITB crossed the lateral femoral condyle is a common examination finding.
ITB pain can sometimes be difficult to reproduce on examination in clinic rooms so functional testing (such as getting a patient to run until the pain occurs and subsequently examining the patient) is often used in diagnosis. Alternatively, a doctor can inject local anaesthetic under the ITB as a diagnostic test. If pain doesn’t occur on running post-injection this also confirms the diagnosis.
Typically imaging (such as an ultrasound or MRI) is not required to diagnose ITB pain syndrome, however, it can be useful to exclude other pathology if the diagnosis is not clear.
Management of ITB pain syndrome
Principles of management of ITB pain syndrome are similar to those of tendon rehab. Deload, strengthen, reload.
You may need a period of rest or decreased running loads to both allow your pain to settle and to strengthen the area to prevent reoccurrence. Strengthening work typically focuses on quadriceps and hip stabiliser (glute med) strength work. A specific program can be developed with the help of a physiotherapist, exercise physiologist, or strength and conditioning coach. A tip here is that weighted Bulgarian split squats are an excellent single-leg exercise to incorporate into a rehab program.
In addition to the above, oral anti-inflammatories can be used in the short term to get the pain under control whilst in the early stages of rehab. If pain persists a corticosteroid injection to the lateral femoral condyle is usually recommended and can provide lasting pain relief. These interventions can be performed by a sports physician.
The ITB is less active when running/walking uphill so it is a good intro step when reloading post-injury. Incline brisk walking on a treadmill can also be an excellent way to keep up your cardio whilst in the rehab/strengthening phase.
It is important that re-loading to full running volumes be increased gradually with specialist help to prevent recurrence of the condition.
Should I foam roll my ITB?
There is no clear evidence that foam rolling your ITB will reduce pain in ITB pain syndrome. From a structural perspective, as the ITB is a band of fascia, it is unlikely that foam rolling would ‘release’ or ‘relax’ the tissue. It also risks further compressing the ITB on the femoral condyle and worsening pain. My advice is generally for patients not to foam roll their ITB, but to get a spikey ball or trigger point device into their TFL and glutes. As mentioned, these muscles feed into the ITB and so loosening or trigger pointing them can relieve ITB pain.
Dr Jim Brennan is a Sport and Exercise Medicine Registrar at Olympic Park Sports Medicine Centre, where he is undertaking training to become a Fellow of the Australasian Sport and Exercise Physicians and a Sport and Exercise Physician. Learn more Jim at https://www.opsmc.com.au/person/dr-jim-brennan/
