Iliotibial Band Syndrome (ITBS) is a common issue seen in runners, or those who have recently started up a running program. This is not to say that it is ONLY seen in runners, but generally those that have lots of repetitive knee bending and straightening can present with this condition (cyclists also common). ITBS is characterised by a burning or sharp pain around the outside of the knee just proximal to the joint. It will usually start at a consistent time point during your run or ride (e.g. always feel it at the 6km mark, or at around the 30-minute point) and continue to get worse during the activity. It also can be further aggravated by downhill running.
Contrary to the name of this issue, it is not the IT band that is the source of the pain. It is actually a highly innervated and vascularised fat pad that sits underneath the IT band (just above the knee on the outside) that gets inflamed and irritated as a result of repetitive compression. This fat pad is a ‘cushion’ and its job is to reduce irritation. The problem arises from having repetitive compression which is above what the fat pad can tolerate. When this happens, the area can become painful and swollen.
ITBS is considered an overuse injury and is primarily driven by a spike in training load (i.e. going from running once per week to three times per week, or quickly going from your normal long run of 5km to a 10km long run). Although training load is usually the catalyst, there are a number of other factors that may be contributing to your ITBS, which is why a thorough examination is important. Hip strength and range of movement, neuromuscular control, gait patterning, foot posture and footwear can all play a part in your presentation.
ITBS rehabilitation can be thought of as a two stage stage process, the first with the aim to calm the area down and the second stage aimed at building up the tolerance of the area.
Stage One – Calm it down
In this stage, we reduce or remove the irritating factors. Ideally, this means identifying the point at which you become symptomatic (e.g. the time you first feel it during your run) and keeping your training below that level. For instance, if you are a runner that feels symptoms at the 35 minute mark of your run, then we keep you running but set a maximum time of 30 minutes so you are staying shy of further irritating the area. Some people will experience symptoms almost immediately and in this case we make other modifications such as uphill treadmill walking as this keeps the knee out of the position which causes the most irritation. In this early stage we also look at addressing any contributing factors in muscle length or strength etc and start an exercise and mobility program targeted towards these areas. Once symptoms are within a 0-3/10 on a 10 point pain scale, we can move to stage two.
Stage Two – Build Tolerance
This stage is about slowly building strength and capacity. This means progressing your strength exercises, starting to incorporate plyometric exercises and moving from uphill treadmill walking to returning to run. During the return to run process, there may also be some technique changes although we try not to alter your technique unless it is absolutely warranted. The process of building tolerance takes time and we are guided by your symptoms, so as long as any discomfort you experience is within that 0-3/10 and doesn’t hang around too long afterward then we are ok to continue to progress. When re-introducing running, particularly downhill running, we can often get flare ups of your symptoms over a 3/10 which is feedback that the area isn’t tolerating the progression. This happens often and is a normal part of rehabbing ITBS so shouldn’t be looked at as a big setback, it just means we need to take a bit more time with the progression.
The end goal should be to get you back to training normally ASAP and from there it is a case of continuing to progress and monitor training load in order to reduce the risk of recurrence further down the line.
