Lower extremity injuries account for over 50% of injuries in college (1) and high school athletes (2), and among lower extremity injuries, the knee is one of the most commonly injured regions. A frequent knee injury, especially among runners, is iliotibial band (IT-band) syndrome. It affects up to 12 percent of runners (3). The pain is generally felt at the distal portion on the IT-band and the lateral femoral condyle. It was originally thought the cause of IT-band syndrome was a result of the distal end of the IT-band snapping over the lateral femoral condyle during knee flexion movements, leading to pain and inflammation. Research from Fairclough, et al., (4) indicated that the potential cause of IT-band syndrome has more to do with the band being compressed in the lateral femoral condyle due to tensions created by the tensor fasica latae (TFL) and gluteus maximus muscles at varying degrees of knee flexion. Many treatment regimens for IT-band syndrome address the distal aspect of the band, however, based upon Fairclough’s findings and consistent with the teachings of NASM, the proximal aspect should also be addressed. Research has also shown that runners affected by IT-band syndrome possessed significantly greater knee internal rotation and hip adduction in comparison to unaffected runners, and that this exaggerated rotation and adduction during the single-leg stance phase of running can lead to increased tension of the IT-band (5). This increased tension can exacerbate compressive stresses of the distal band along the lateral femoral condyle leading to symptoms.
To determine possible risk for IT-band syndrome or to identify the potential reason why someone may have developed the condition, movement assessments (such as the overhead and single-leg squat assessments) should be performed. Based upon the aforementioned research, a key compensation to look for when performing the assessments that can contribute to IT-band syndrome is if the knees move inward (knee internal rotation and hip adduction) when performing the squatting motions (Figures 1 and 2). It will also be important to observe for any foot and ankle compensations as restrictions in the foot and ankle can lead to compensations at the knee and hip (6). A key compensation to look for at the foot and ankle is if the feet flatten and/or turn out during the assessment (with concomitant knee internal rotation and hip adduction) (Figure 3). If foot, knee, and hip compensations are observed, you can confirm if the knee and hip compensation is due to ankle restriction by performing the assessments with the heels elevated on a two-by-four board or weight plates (Figure 4). This strategy puts the ankle into a plantarflexed position and essentially gives the ankle joint more range of motion when squatting. If the knee and hip compensations improve with the heels elevated, then the foot and ankle will need to be addressed as part of your corrective strategy. If the knee and hip compensations do not improve with the heels elevated, then the primary region to address would be at the hip.
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Corrective Strategies for IT-Band Syndrome
Following NASM’s Corrective Exercise Continuum programming strategy can help address potential muscle imbalances that may be contributing to movement compensations which lead to IT-band syndrome. First, inhibit the muscles that may be overactive via self-myofascial release. Key regions to address with foam rolling when the feet flatten/turn out and the knees move inward include the calves (if foot compensations are identified), IT-band, adductors, and TFL (Figures 5-8). Foam rolling is particularly important to address the IT-band since it is difficult to stretch. Next, lengthen the calves, adductors, and TFL with static stretching (Figures 9-11). Once the overactive muscles have been addressed, activate the underactive muscles. Key areas to target with isolated strengthening are the posterior tibialis (if foot compensations are identified) with single-leg heel raises (Figure 12), the gluteus medius with side-lying wall slides (Figure 13), and gluteus maximus with ball bridges (Figure 14). Finally, perform an integrated exercise to improve muscle synergy to enhance neuromuscular efficiency and overall movement quality. This can be done by performing a squat (keeping the feet in line with the toes) to an overhead press (Figure 15A and B).
IT-band syndrome is a common condition that can be very painful and debilitating. Having a way to assess someone’s predictability of developing the condition and a corrective strategy to improve the movement deficiencies that can lead to the condition will greatly help those at risk. To address the issue of IT-band syndrome, look for knee and ankle compensations via the overhead and single-leg squat assessments and utilize NASM’s Corrective Exercise Continuum (Inhibit > Lengthen > Activate > Integrate) to improve movement quality to decrease the risk of developing or rectifying this condition.
- Hootman, J.M., R. Dick, and J. Agel. (2007). Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. Journal of Athletic Training, 42(2):311-319.
- Fernandez, W.G., E.E. Yard, and R.D. Comstock. (2007). Epidemiology of lower extremity injuries among U.S. high school athletes. Journal of Athletic Training, 14(7):641-645.
- Fredericson, M., & Wolf, C. (2005). Iliotibial band syndrome in runners: innovations in treatment. Sports Medicine, 35:451-459.
- Fairclough, J., Hayashi, K., Lyons, K., Bydder, G., Phillips, N., Best, T.M., & Benjamin, M.(2006). The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome.Journal of Anatomy, 208(3):309-316.
- Falvey, E., Clark R.A., Franklyn-Miller, A., Bryant, A.L., Briggs, C., & McCrory P.R.(2010). Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scandinavian Journal of Medicine and Science in Sports, 20(4):580-587.6. Bell, D.R., Padua, D.A., & Clark, M. A. (2008). Muscle strength and flexibility characteristics of people displaying excessive medial knee displacement.Archives of Physical Medicine and Rehabilitation, 89(7):1323-8.