Iliotibial band massage and foam rollers for iliotibial band syndrome

Regarding iliotibial band syndrome, a reader asked recently:

What is your opinion on the use of a dense foam roller on the hip, glutes and sides of the thigh? Does it do anything or is it just another snake oil solution?

Foam rollers have limited usefulness in the treatment of IT band syndrome, but are probably not quite as bad as “snake oil.” Most people use foam rollers for this condition imagining that it is a form of deep massage for the IT band itself, intended to lengthen the IT band, and this is no more possible with a foam roller than it is with any of the other very intense IT band massage techniques. Like any deep massage of the IT band itself, there is at most a minor and temporary change in the texture/length of the IT band, but it is simply too tough a structure to be actually be “lengthened” by this or any other method short of a scalpel. I’ll explain this in much more detail below.

What makes foam rollers potentially useful for the self-treatment of IT band syndrome is that they are a particularly good self-massage tool for the hip musculature. They may be a good way to aid trigger point therapy in the hips, specifically in the tensor fascia latae and gluteus maximus muscles, which control the tension of the IT band directly. To the extent that foam rollers help that process, they are relevant.

But that’s not that great an extent. I think that trigger point release in these two muscles is technically relevant to ITBS, but in practice it yields only a minor benefit to the condition. Trigger point release is an uncertain business. Even if you can pull it off in this area, the question remains: does a small amount of temporary loosening of the IT band even help? It’s somewhat akin to loosening your shoelaces to try to deal with a rock in your shoe. If the rock is still there, loose shoes is probably not going to do a lot of good. This is one of the major points of my ITBS tutorial.

Because it’s so common, the remainder of this post is an excerpt from the tutorial about massaging the IT band itself, explaining exactly why it’s almost entirely pointless.

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Direct treatment of the IT band and the underlying quadriceps muscle is the most common kind of massage therapy offered for iliotibial band syndrome, and probably also the most simplistic and useless. Typically, strong Swedish massage is used to allegedly “lengthen” the IT band and or “unstick” it from the underlying quadriceps, and the intention of this treatment is rarely any more complicated than that. Patients are routinely instructed to perform the same massage treatment on themselves using a foam roller at home. It’s a painful place to massage strongly. In this section, I’ll show that it’s also almost completely pointless.

Some therapists may also claim that the underlying quadriceps (vastus lateralis) muscle is also the target of the treatment, but they’re unlikely to have a clear idea how quadriceps massage is supposed to help, and the focus will usually still be on the IT band.

So what’s the problem with these treatments? They betray a lack of understanding of the condition, the anatomy, and of connective tissue.

The IT band is unbelievably tough

The iliotibial band syndrome is a massive structure, the largest tendon in the body, made of a bio-rope stuff that is slightly elastic but with a greater tensile strength than steel cable. It cannot be elongated by any known method short of surgery, and certainly not by rubbing it or (even sillier) rolling over it. Here’s an absurd exercise to demonstrate how silly it is:

1. Measure a leather belt.
2. Stretch the belt on the edge of a table.
3. Grease up your elbow with some lubricant.
4. Slide your elbow along the length of the leather belt. This patient feels no pain: be as brutal as you can stand.
5. Re-measure the belt. How’d you do?

Now consider that leather is actually less strong that tendon. Leather is skin — remarkably tough, with a much lower tensile strength than tendon, and actually much easier to tear. Indeed, tendons are so tough that they basically don’t tear. Ever. For any reason. Muscles will tear before tendons tear! Tendons will rip of a chunk of the bone they are attached too long before they tear (called an avulsion fracture) — because bone has a lower tensile strength, and is the weak link. Starting to get the picture? Even if you halved the thickness of that belt, hung it from a strong hook in the ceiling, and pulled on it with all of your body weight, it would probably still hold you.

So … good luck trying to “elongate” the IT band with massage.

Even if you could elongate the IT band by rubbing it, this would surely not be the easiest way of doing so. This is a tendon we’re talking about here: tendons are what tie muscles to bones. If you want to change the tension on a tendon, change the behaviour of the muscle. That’s not easy either, but at least it makes a certain amount of logical sense. If you want to loosen your hamstring tendons, should you massage the tendons? Or the hamstring muscles? The muscles, of course!

The iliotibial band syndrome is a massive structure, made of a substance with a greater tensile strength than steel cable.

The dead giveaway that therapists who do this treatment are really not thinking it through is that they usually ignore or minimize the hip muscles: the muscles that actually control the tension on the iliotibial band. I know that this is the case because I ask clients, “Did your previous massage therapist work on muscles in your hip at all?” They routinely reply, “Nope, just the side of the thigh.”

If these therapists were trying every possible way of loosening the iliotibial band, I could perhaps forgive their attention to the tendon itself, but they are not: they are typically hammering away at the toughtest tendon in human anatomy, while ignoring the muscles that actually pull on it and control its tension.

What about thixotropic effect?

Some therapists might try to argue that “thixotropic effect” is the method behind their madness. An obscure property of connective tissue, thixotropic effect is the tendency of connective tissue to become softer when heated and kneaded. This is a real thing. However, thixotropic softening is a really transient effect: as soon as the heating and kneading stops, the connective tissue rapidly reverts to its previous state, like a piece of warm plastic thrown into a snowbank.

What about adhesions?

Some therapists justify IT band massage by arguing that the IT band is “stuck” (adhered) to the underlying quadriceps, and that this accounts for IT band tightness. But this hopelessly confuses the ideas of elasticity, tightness and freedom to slide. Like thixotropy, adhesions are a real thing — tissues can become stuck together by a slight chemical bonding of hydrogen atoms that protrude from the surfaces of connective tissues like the hooks and loops of Velcro. The elasticity of tendon is dependent entirely on the molecular structure of the protein molecules that make it up ... not on the ability of layers of connective tissue to slide over each other.

The adhesions justification is particularly out in left field because ignores the normal anatomy of the IT band, which is actually anchored to the femur for most of its length — it’s not free to slide in the first place, so it can hardly be deprived of that power by adhesions! You can’t make the IT band for lengthwise sliding without quite a bit of messy work with a scalpel.

And, even more important, even if you could, it’s still not the same thing as “loosening” the IT band. A tight IT Band could, in principle, slide just fine. Tight muscles and tendons generally do slide over underlying structures just fine. Freedom to slide and tightness are simply not the same thing.

The adhesions justification is emptier still: adhesions probably don’t even exist under the IT band to any significant degree anyway. But such adhesions are only a clinical problem in people who are significantly immobilized due to paralysis, and even then they can be broken up relatively easily — this is just stickness, not scarring. In active people — like virtually all patients with IT band syndrome — it is basically impossible to develop any significant adhesions, anywhere in the body.

So, adhesions: probably don’t exist in this location, have nothing to do with IT band tightness at all, and can’t prevent slide the IT band never possessed in the first place. So it’s really quite the mystery why therapists are so busily trying to break them.

What about the quadriceps?

Some therapists may argue that long, deep strokes up and down the length of the iliotibial band are actually intended to massage and treat the quadriceps.

Trigger points in the quadriceps might contribute to pain, tightness and dead heavyness in the thigh and knee. To the extent that quadriceps massage relieves those possible trigger points — which will not be great, if all that’s done is long, deep strokes instead of proper trigger point therapy — it might provide some temporary symptom relief. “Happier” quadriceps musculature could also lead to slightly altered hip and knee function, and thus it’s conceivable that there would changes in IT band syndrome — but would those changes be beneficial? Lasting? Or significant? No one knows any of that.

Dubious as those possible benefits are, they rarely seem to be the actual therapeutic intention of the technique, and thus they are unlikely to be pursued competently. The fantasy of IT band lengthening is likely to be the focus of treatment, with quadriceps treatment proposed as a tepid “bonus” justification.

Sadly, I have also seen therapist justify quadriceps massage with yet another grave misunderstanding of anatomy: they think that the quadriceps actually controls IT band tightness directly. This is a “not even wrong” problem — it’s so wrong that it’s not clear what they think that they know. Quadriceps are not anatomically related to IT band tension, period.