IT Band Syndrome
Iliotibial Band Syndrome (IT Band Syndrome) is named for a collection of symptoms to describe lateral knee pain and tightness that runs from just past the knee up side of the thigh to the hip. Anytime you hear or see the word syndrome associated with a musculoskeletal condition, know that the particular cause of this pain and dysfunction is disputed amongst clinicians and treatment can vary, depending on who you listen to. When runners, hikers, and walkers come into my clinic with the typical suite of IT Band Syndrome symptoms, I look at two things: Their hip and their quadriceps.
Weak hip abduction and poor stabilization of the hip are almost alway present when IT Band Syndrome rears its ugly head. Abduction of the hip involves moving the hip sideways, away from the midline of the body. Stabilization of the hip involves keeping the femur lined up under the pelvis when in weight bearing. Both movements involve the interaction of the Glute Maximus, Medius and Minimus muscle group as well as the TFL (Tensor Fascia Latte) muscle. These muscles are at the top and lateral part of thigh while the IT Band is their long tendon that extends down the side of the thigh, inserting at both the lateral end of the femur and at top of the tibia. Not to get to far into the anatomy weeds but the glute minimus’ fibers do not invest directly into the IT Band. However, this muscle is an important abductor of the hip and when weak, it is a contributor to the symptoms of IT Band Syndrome. Furthermore, the Glute Maximus’s primary role is hip extension, with just its uppermost fibers contributing to hip abduction.
When the muscles involved in hip abduction and stabilization grow weak we see a breakdown in the control of lateral movement at the knee and hip. The knee is not supposed to bend laterally (or medially for that matter). Because the IT Band extends down past the knee joint, it helps control and absorb lateral forces acting on the knee. In short, the IT Band along with other structures keep the knee aligned to perform its primary functions of flexion and extension. If our hip abductors are weak, there will be an excessive amount of force on the knee, causing pain and an inflammatory cascade at and around the insertion point of the IT Band.
If we look up the chain at pelvis, those weak hip abductors will have trouble keeping the pelvis level when we plant our foot walking, running, hiking, climbing stairs, etc. In fact, if the hip abductors don’t do their job, our pelvis will tilt towards the side of the foot that is in the air. This tilt elongates the IT Band, again irritating the fibers at its insertion, causing pain and an inflammatory cascade.
Turning our attention to the quadriceps muscle, which is the big guy on the front of your thigh that, hence the name, is an actually group of four muscles. These muscles extend down the front of the thigh converging to form the quadriceps tendon. This tendon inserts into and envelopes the patella(knee cap). When the quadriceps muscle group is weak and/or overworked it can alter the path of the kneecap, causing an inflammatory cascade that will contribute to the symptoms of IT Band Syndrome. It also causes a painful condition called patellofemoral pain syndrome. An exhaustive description of this condition can be found here:
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Now that we know the cause of IT Band Syndrome, we have to go about fixing it. Like many (certainly not all) orthopedic injuries plan on a time frame that lasts 4-8 weeks depending on the severity of the connective tissue irritation and your relative musculoskeletal health. When helping my patients rehab this injury, I take them through three distinct stages.
Stage 1
In this stage we are building strength, maintaining endurance, and removing tension from the target muscle groups, all while reducing pain. For strength training we are focusing on exercises that strengthen those hip abductors and flexors, while in a non-weight bearing position. By exercising our hip abductors and quads while laying on our back or side, we avoid the ground reaction forces that will put too much lateral stress on the IT band. Whether at this point we can add some exercises that bend and extend the knee all depends on the severity of the injury.
In this stage I like to have my patients walk on the treadmill, with an incline. This helps maintain their endurance, while gently strengthening the motions of hip extension and stabilization. This can cause a bit of pain, but if it is less than 5 out of 10, that is acceptable.
Finally, we have to remove the tension from the hip abductors and the quadriceps with some mobility work. While manual therapy from an experienced therapist is more efficient, this can be done at home with a couple tools. At the hip I like to use a lacrosse ball as those muscles sit in the relatively small nooks and crannies formed by the femur and the pelvis. For the quadriceps I suggest a lacrosse ball or a foam roller.
We can move on to Stage 2 when there is very little to no pain during daily activities like descending stairs or a decline. This can take 2-3 weeks.
Stage 2
This stage involves relatively heavy and slow resistance training and should last 2-4 four weeks to give the body enough time to respond to the stimulus and start showing an increase in strength. Use a weight that will limit your repetitions to 8-12 repetitions over 3-4 sets. This stage still requires the mobility and treadmill work.
The strengthening at this stage is done in a standing position. If there is still a bit of pain, start with exercises that have both feet on the ground. If you are pain free, start with exercises that require you to balance on one leg. For our hip abductors we want to use exercises that require us to move laterally. For our quads, we want to focus on exercises that bend and extend our knees like squats, single and double legged. Additionally, we want to start isolating our core with front and side planks.
Stage 3
In this stage we spend 2 weeks preparing ourselves to return to sport by adding in plyometrics. In short, plyometrics are exercises that involve jumping and/or hopping to drive acceleration and deceleration stress to through muscles and connective tissue of our lower extremity. We want to add forward and lateral hops, as well as adding a jumping component to exercises like lunges and squats. In adding plyometrics to our exercises we are preparing our connective tissue to be able to absorb dynamic and repetitive movements like running, biking, hiking, and yes even walking. In this stage I ask that patients continue with the treadmill walking and the mobility work. Once we have spend a couple weeks in this stage it is time to return the patient to their sport!
IT Band Syndrome, while frustrating and painful, responds well to a structured rehabilitation approach that addresses the root causes rather than just treating symptoms. The key is understanding that weak hip abductors and quadriceps are usually the culprits behind this condition. By following a progressive three-stage protocol that builds strength, maintains endurance, and prepares the tissue for dynamic movements, most patients can return to their activities within 4-8 weeks. Remember, proper form during exercises and consistency with the protocol are essential. Don't rush the process – giving your body adequate time to adapt will lead to better long-term outcomes.