Yeah, What About it?

Sure, most athletic trainers have heard of the iliotibial band, but too often it’s not considered when assessing knee and hip pain.

By P.J. Gardner

P.J. Gardner, MS, ATC, CSCS, is an athletic trainer with Physiotherapy Associates, in Memphis, Tenn., and works with student-athletes at Overton High School, in Memphis.

Training & Conditioning, 11.2, March 2001,

Athletic injuries run the gamut from skin lacerations to broken bones, from pulled muscles to torn ligaments. Athletic trainers can readily diagnose and treat most injuries to these structures. But in the case of the iliotibial band (ITB), a slew of injuries and complaints can be attributed to a structure that is neither muscle, tendon, ligament, nor bone.

The ITB is a thick fibrous sheath covering the lateral portion of the leg. It is usually paid little attention—until it is injured. In athletic training rooms across the country, ATCs give athletes advice on everything from proper nutrition to rehabilitation techniques for all the major muscles, yet rarely does the ITB come up. In fact, it is all too common to show athletes quad, hamstring, and calf stretches and have them go through a complete warmup without any mention of stretching the ITB.

The ITB has been relegated to this position in large part because, being neither muscle, tendon, ligament, nor bone, it is difficult to visualize. But it has great importance in a wide variety of orthopedic complaints—prime among them, generalized but serious knee and hip pain. Runners and cyclists are afflicted most commonly, but ITB friction syndrome—pain caused by the ITB constantly rubbing over the lateral epicondyle of the knee—can strike any athlete.

Anatomy and Physiology
The ITB is a complex structure consisting of three parts. The first is the tensor fascia lata, which is the muscle starting at the iliac crest. The second component is the iliotibial tract, which extends down to the third part, the actual ITB. Usually, the combined three parts are referred to as the ITB.

From its attachment on the iliac crest, the ITB runs down the lateral part of the thigh, and attaches at its other end to the lateral tubercle of the tibia (also known as Gerdy’s tubercle). Fibers from the ITB also project anteriorly from the gluteus maximus. It connects on the femur and acts as a stabilizer to the quadriceps. The deepest fibers of the fascia attach on the lateral aspect of the femur to the linea aspera, and other middle fibers blend into the lateral retinaculum at the patella.

The entire structure assists in flexion and extension of the knee and abduction of the hip and acts as a lateral stabilizer to both. As such, the ITB is an integral part of gait-pattern mechanics.

When It Gets Noticed
When it becomes stiff and tight, the ITB can cause a great deal of pain at the side of the knee or, less often, the hip. Athletes will complain of lateral knee pain when running or walking. The pain can become very severe in a short period of time. Tenderness, crepitus, swelling, stabbing pain, and snapping have all been used to describe the type of pain reported with ITB friction syndrome.

The angle of greatest irritation is approximately 30 degrees of knee flexion. Activities that repetitively put the ITB in this impingement zone increase the risk for developing ITB friction syndrome. There are several tests that can be used to determine if an athlete has tightness in the ITB or is suffering from ITB syndrome (see Sidebar “Identifying ITB Friction Syndrome,” at the end of this article).

ITB pain can develop as a result of poor training programs. If an athlete increases his or her running or cycling mileage too quickly, it can trigger a painful response (training distance should not be increased by more than 10 percent per week). Running on a crowned surface and running downhill also seem to cause problems.

There are other factors that come into play as well. Athletes who are bow-legged or who have a large Q angle or leg-length differentials seem to be more prone to ITB irritation. Athletes with excessive foot pronation, lower-extremity weakness, and younger athletes experiencing a growth spurt may also be more susceptible to ITB injury.

The evaluation process to determine the cause of the pain can be challenging. Be sure to ask extensive questions about training programs, including warm-up and cool-down times, and about the volume, intensity, duration, and frequency of all exercises and drills. Many athletes will tell you they do not spend much time warming up and stretching. They often simply start right in on high-intensity training. Their problem could be that easy to reveal, or it could be much more subtle.

It is also important to examine the athlete’s footwear. Excessively worn sneakers can fail to provide adequate stability, especially at heelstrike and during the support phase of running. In overpronators, varus wedges may be an effective treatment, as long as the prescription is properly carried out. Improper use of varus wedges or overcompensating for the overpronation can actually cause ITB friction syndrome.

As mentioned, ITB syndrome most often hits runners and cyclists, because of the repetitive motions of those activities and their tendency to put the knee in the impingement zone. However, it can develop in any athlete. If pain occurs, resistance training and running for cardiovascular development should be monitored. It’s not necessarily the sport movements that elicit the pain; it may be the conditioning required for the sport that causes irritations.

The most common mistake is not warming up and stretching properly before and after sport training. Once symptoms begin to occur, stretching and warming up become much more important to help increase flexibility and decrease pain. In some acute cases, this is all the intervention needed to decrease symptoms. If the debilitation is severe, referral to a medical doctor may be necessary.

Getting Back in the Game
Symptoms need to be treated as soon as possible for best long-term results. In the most severe cases, an immobilizer will be prescribed to keep the athlete’s knee from moving and to allow the irritated area to calm down. Often, doctors will prescribe anti-inflammatories, and in serious cases, corticosteroid injections may be necessary. One to two weeks of inactivity may be required before training can be resumed.

Moist heat or cold packs can be utilized early, followed by ultrasound or phonophoresis to the most irritated area (usually, the lateral knee). Sometimes, the greater trochanter will be involved too, so check for tenderness in that area as well.

Other conventional treatments for ITB irritations include trigger-point (TP) therapy and deep-friction massage. TPs may develop anywhere in the muscle tissue and interfere with normal function. Since the ITB is not truly muscle tissue, the trigger point is actually in the muscle underneath the ITB (often, the lateral quadriceps), but the TP can refer pain or other sensations to several areas of the leg. TP treatments involve applying direct pressure on a known TP to help relieve local muscular spasticity and referred pain or other sensation. This treatment helps reduce pain and promote relaxation. Deep-friction massage is used to increase circulation to the affected area and help elongate and re-align soft tissue fibers which may, in turn, improve functional ability.

Both of these treatments are utilized in a rehab setting and are generally not included in strengthening and stretching programs, which are the focus of this article. For more information on both of these treatments, see “Rubbing Out the Injury,” in T&C May/June 1999, and “Targeting Trigger Points,” in T&C October 2000.

Stretching will not only help prevent recurrences, but seems to help alleviate pain once it can be tolerated. There are several stretches that can be effective. The standing wall lean is a good universal stretch to begin with. The Ober stretch and prone quad or hip-flexor stretch can also be used to gain lower-extremity flexibility (see Sidebar “Stretching It Out,” at the end of this article).

Once the inflammation is reduced and movement does not cause pain, the athlete can then begin therapeutic activities. When running or cycling are a primary part of the athlete’s training, it is especially important to begin with low volume and intensity. Pain-free training is the key, regardless of the distance.

One unique training adjustment for runners returning from ITB injuries is to return them to activities requiring a faster-than-normal training pace and/or multidirectional movements. The faster pace and multidirectional aspect of sports like basketball and racquetball help keep the knee out of the impingement zone. Slower-paced running can then be attempted once the athlete has performed the faster-paced movements asymptomatically. This approach is contraindicated for most other lower-body injuries, but because of the nature of the ITB, it has found great success.

Resistance Training
Once modalities and a regimen of stretching have been started and pain has begun to decrease, strength training can begin. For general hip and lower-extremity strength, four-way straight-leg raises are a good starting point. Weight can be added as tolerated. Knee extension and hamstring curls are also excellent lower-extremity exercises. Start with low volume (two sets of 10 to 15 pain-free repetitions). Progress to closed-chain movements, such as squats and lunges. Do not advance to more difficult movements until lower-level movements can be performed asymptomatically.

ITB pain can become a chronic injury if not treated correctly. It can hinder athletic performance and shorten athletic careers. This article provides guidelines for treating ITB syndrome, but there are a variety of exercises and protocols that are effective. The key is to identify and treat the symptoms early and to not allow the condition to become chronic. Make sure your athletes are educated on the importance of keeping the ITB and its surrounding muscles strong and flexible. And maybe that way, they won’t have to ever hear the words “iliotibial band” again.

Sidebar - Identifying ITB Friction Syndrome
The following tests can be used to determine if an athlete has ITB tightness or is suffering from ITB friction syndrome. It is important to periodically test athletes for tightness, particularly those athletes who may have inherent contributing factors such as being bow-legged or having a large Q angle, leg-length differential, excessive foot pronation, or lower-extremity weakness. This at-risk group also includes younger athletes experiencing a growth spurt and certainly any athletes experiencing pain in the lateral part of the knee or hip. If the athlete shows tightness along the ITB or other muscles in the area, the same actions that make up the test can be used to stretch the tight area out. For more stretches, see Sidebar “Stretching It Out,” to follow.

Modified Thomas Test
This test assesses tightness of the rectus femoris, iliopsoas, and tensor fascia latae muscles, as well as of the ITB. Have the athlete lie on a table on his or her back with the buttocks positioned at the edge of the table. The athlete should then hold both knees to his or her chest as the athletic trainer slowly lowers the affected leg back toward the floor. If the athlete cannot achieve 90 degrees of knee flexion, a neutral angle of hip flexion, and less than 15 degrees of hip abduction relative to the pelvis, he or she is considered to have tightness in this area. Tightness does not necessarily mean the athlete is suffering from ITB syndrome, but if steps are not taken to increase flexibility in this area, ITB syndrome becomes a distinct possibility for the athlete’s future.

Ober Test
With the athlete lying on his or her unaffected side, abduct the affected leg 45 degrees or greater, if possible. Extend the hip in order to clear the ITB over the greater trochanter. Be sure to keep the hips in a neutral position, perpendicular to the testing surface, in order to keep the ITB relaxed. Gently lower the abducted leg. If the leg remains in the abducted position, the test is considered positive for ITB contracture. If the leg drops into an adducted position, the test is considered normal. If the patient shows tightness along the ITB with this test, have him or her perform Ober stretches (same as the Ober test).

Noble Compression Test
Have the athlete lie on his or her back or unaffected side with the knee of the affected leg flexed 90 degrees. Apply direct pressure to the lateral femoral epicondyle while straightening the knee. The test is positive if pain is reproduced on the epicondyle at or around 30 degrees.

The Renne Test
Similar to the Noble Compression Test, but instead of lying down, the athlete stands on his or her affected leg and performs a mini-squat, flexing the knee to at least 30 degrees. If he or she experiences pain at the lateral femoral epicondyle, the test is positive.

Sidebar - Stretching It Out
Once the athlete can tolerate stretching, it is important to start him or her on a regimen to keep the ITB flexible. The following are stretches specifically for the ITB and its surrounding structures.

Standing Wall Lean
The athlete should stand with the unaffected leg crossed over the affected leg and the upper body stabilized with the outstretched hand against the wall while the opposite arm helps push the affected side toward the wall.

Ober Stretch
This stretch can be done alone by the athlete, or with one or two people assisting. The stretch is identical to the Ober Test (see “Identifying ITB Friction Syndrome,” above).

Prone Quad or
Hip-Flexor Stretch
With the patient lying prone, have him or her bend one knee and reach back and grab the foot, and gently pull it toward the buttocks.

Trunk Rotations
This stretch focuses on the gluteus maximus and piriformis muscles and can easily be done by the patient alone.

Standing ITB Stretch
This stretch incorporates trunk lateral flexion and rotation. The athlete’s involved leg should be behind his or her uninvolved leg.