Iliotibial band syndrome (ITBS) is a painful injury of the connective tissue in the outer thigh that affects more than 200,000 Americans each year. This overuse injury can throw a wrench into even the fittest athlete’s training schedule. But despite the fact that it’s inconvenient and uncomfortable, ITBS is actually quite treatable. With an early and proper diagnosis, ITBS can be overcome in six months or less. And with a few simple lifestyle adjustments, people with ITBS can minimize their symptoms during flare-ups and prevent future re-injury.
ITBS is an overuse injury that affects the connective tissue in the outer thigh and knee. Though it is most common among runners and bicyclists, ITBS can affect almost any type of athlete. Pain and swelling begin in the knee, and for this reason, many people mistake ITBS for other types of knee injuries. A simple test can determine if knee pain is related to ITBS or something else altogether. If, when the knee is bent at a 45-degree angle, the pain is located in the outer knee, it is likely ITBS. If the pain is located in another part of the knee, it is likely something else. A specialist can verify this diagnosis using MRI technology.
The primary symptom of ITBS is pain in the outer (lateral) knee that can eventually radiate along the outer thigh and up to the hip. This pain can be accompanied by popping or snapping sounds in the knee and some swelling in and around the knee.
ITBS is swelling of the iliotibial band (IT band). The IT band is a thick band of connective tissue that runs along the outer portion of the leg, from the top of the outer hip (iliac crest) all the way down to the upper portion of the shinbone (tibia). As the leg shifts from a bent (flexed) position to a straight (extended) position, the IT band passes from slightly behind (posterior to) the outer knee to slightly in front of (anterior to) the outer knee. This movement is cushioned by a fluid-filled sac called a bursa. When the bursa or another part of the knee becomes inflamed, the movement of the IT band causes friction. This leads to IT band swelling, or, in other words, ITBS.
For the most part, ITBS is an injury incurred over a sustained period of repeated activity. When there is a slight misalignment in the body—meaning the skeleton is not stacked properly and the supporting muscles, ligaments, and tendons cannot function optimally—repetitive motion can exacerbate the effects of misalignment. Causes for such misalignments as they relate to ITBS can be internal or external.
Internal causes are imbalances somewhere in the body that lead to misalignment in the knee and/or hip. Examples of internal causes are:
•Foot supination (excessive pressure on the outer foot)
•Pigeon-toed stance (toes toward each other and heel away from each other)
•Bowed legs (legs that curve outward, mimicking the shape of an archer’s bow)
•Leg length discrepancy (difference between the length of the left and right legs)
•Abnormal pelvic tilt (uneven hips that dip to one side or another)
•Lack of flexibility in the supporting muscles (like the quads and hamstrings)
•A discrepancy in flexibility between the left and right leg
•Lack of strength in the supporting muscles (like the abductors)
•Improper training habits during activities like running, bicycling, rowing, and weightlifting
External causes are those that relate to the environment. These are especially common among athletes. Some examples of external causes include:
•Running on roads where the center is higher than the outer edge (essentially causing a leg-length discrepancy)
•Bicycling with misaligned toe-clips
•Wearing worn-out shoes (causing supination)
- Wear supportive shoes. If your shoes are worn out along the outer edge, your risk for developing or worsening ITBS increases. For proper support and alignment, your shoes should be supportive; both the shoes you wear every day and those you wear to exercise. If you suffer from ITBS, it may help to visit a podiatrist and get orthotic inserts.
- Warm up. Before any strenuous activity, be it a workout, run, or long walk around the neighborhood, make sure to properly warm up the body. Warming up increases blood flow to all the major muscle groups and literally generates heat throughout the body. A warm-up readies the body for the task you’re about to perform and greatly reduces the risk of injuries like ITBS. For more information about effective warm-ups, see our article, Mobilizing Warm Up 101.
- Avoid inflammatory foods. Eating highly processed, inflammation-inducing foods can exacerbate symptoms of ITBS by adding more inflammation to an already swollen area. Make whole foods 95 percent of your daily diet, leaving processed and junk foods for special occasions. To further reduce the symptoms of ITBS and help prevent its reoccurrence, focus your diet on anti-inflammatory foods.
1. Ground the Feet. If your weight is disproportionately shifted toward the outer part of the feet, the risk of ITBS increases. Grounding the feet ensures equal distribution of weight on each foot, essentially removing the potential for favoritism toward the inside or outside of the foot and setting up the foundation for good alignment in the rest of the body. To Ground the Feet, first create equal pressure on the left and right foot. Then, imagine points at the base of your big toes, pinky toes, outer heels, and inner heels. Pull the toe stems long and push all four points of the soles into the ground. In everyday life, you can Ground the Feet when you stand in line at the grocery store, brush your teeth, or sit at your desk at work. No matter if you’re seated or standing, connect to the ground beneath you by simply pressurizing through the four points of the soles (with equal weight on both feet), and reach long through the toes.
2. Support the Knees. An unsupported knee typically means improper alignment with the rest of the leg. A focus on supporting the knees reduces the risk of misalignment-related ITBS. To Support the Knees, imagine a point at the center of each kneecap. Standing naturally, notice if these points face directly forward or off to the side. Now, adjust the feet so you are standing parallel, and align the kneecaps directly forward—they will be roughly in line with your middle toes. As you bend your knees, challenge yourself to keep the knees stacked above the ankles with the center of the kneecaps facing forward. In everyday life, you can Support the Knees life while climbing the stairs. Maintain equal pressure on the base of the big toes and the base of the pinky toes. As you climb the stairs, face the hips directly forward, and maintain the alignment of the knees directly over the ankles.
3. Anchor the Hips. When dealing with pain or injury, it is best to address not only the joint where you experience the most symptoms, but also the joints just above and below that point. You already know how to Ground the Feet (the joint below). Now, Anchor the Hips to ensure the ITBS isn’t being overstretched or overcontracted at its origin point on the hip. To Anchor the Hips, make “L” Mudra with your hands. Place your thumbs on your ribs and your index fingers on your hips. The space between the thumbs and the index fingers is called the side body. This area shortens when you slump or slouch. Increase the space between the index fingers and thumbs to lengthen the side body. Now, draw the lower belly—the space between the belly button and the pubic bone—back toward the spine and up toward the ribcage to engage the deepest layer of abdominal muscle (transverse abdominis). Finally, release the glutes (butt muscles). To learn to release your glutes, it may help to understand what it feels like to do the opposite—grip the glutes, by squeezing them together. Now release. In everyday life, you can Anchor the Hips when standing up from a chair. Before rising, lengthen the side body. On an exhale, Ground the Feet, and simultaneously pull the belly in toward the back and up toward the ribcage and release the glutes to stand.
Apply ice. Place an ice pack, wrapped in a towel for comfort, to the injured area—15 minutes on, 45 minutes off—every hour that you’re awake for the first week after injury, then three to four times a day thereafter until the pain dissipates. The cold temperature will reduce inflammation and the buildup of tough, inflexible scar tissue. In the moment, it will also alleviate some of the pain you may be experiencing. Long-term, icing ensures you are able to maintain optimal range of motion.