last updated 53 days ago, Dec 17th, 2009
Side of your knee hurt?
IT band syndrome is a common and often persistent knee injury, causing pain mainly on the side of the knee.
Save Yourself from
IT Band Syndrome!
AN ADVANCED TUTORIAL FOR PATIENTS AND PROFESSIONALS
All your treatment options for Iliotibial Band Syndrome reviewed in great detail, with clear explanations of recent scientific research supporting every key point
by Paul Ingraham, Vancouver, Canada (qualifications)
selected illustrations by Paul Ingraham,
Alexia Tryfon,
Lindsay McGee
Welcome to the largest and most scientifically current tutorial about IT band pain available anywhere. This is not just a web page: it’s a detailed book for patients and professionals. Thousands of readers have benefited from it and contributed their stories. If you have a tough case of chronic IT band syndrome, this is the information jackpot you’ve been looking for. What works for IT band syndrome? What doesn’t? Why? You simply will not find better information about IT band pain.
Iliotibial band syndrome (ITBS) — which is also known as iliotibial band friction syndrome — is a common and often persistent injury primarily afflicting runners, as well as some cyclists and hikers, and causing pain mainly on the side of the knee (not the hip, not the thigh — that’s something else).
In the years since I started treating and writing about IT band syndrome, there has been an explosion of free information about it available on the internet. Sadly, this has not resulted in patients or health care professionals being better informed. Quite the opposite, I’m afraid. Most of the information that you can find out there repeats the same oversimplified conventional wisdom … most of which is just wrong.1
Unfortunately, ineffective therapies for IT Band syndrome are recommended everywhere
Canadian Running Magazine published a featured story about ITB syndrome. Among other serious errors, the article especially promotes the “hip strengthening” myth — the idea that hip strengthening will prevent and cure ITBS, a theory that is easily and thoroughly debunked in this tutorial, with the support of credible research and medical expertise.
Canadian Running magazine gets it wrong
The July 2008 issue completely botches their article on the subject, promoting a half dozen common myths.
Here are some other examples of obsolete IT band treatment that patients often encounter. Detailed scientific evidence supporting all of these points will be provided further along in the tutorial.
- Massage therapists still try to “elongate” your iliotibial band with deep stroking Swedish massage — which works about as well as it would on a truck tire — but often ignore the muscles that actually control the tension on the iliotibial band, such as the tensor fascia latae and gluteus maximus.
- Physiotherapists and chiropractors still routinely prescribe IT band stretches in spite of good evidence that they do not work … especially the incorrect ones often prescribed! Another common physical therapy blunder is to prescribe quadriceps training — a blatantly irrelevant therapy that doesn’t even work for the problem it’s actually supposed to be good for (patellofemoral pain syndrome).
- And, as you have probably discovered already, most doctors are uninformed about iliotibial band syndrome,2 and often do not know anything at all about medical options like cortisone injections or IT band release surgery, which might actually help — but are not actually the first or even second line of defense. Even many sports medicine doctors and orthopedic specialists simply don’t know enough about IT band syndrome to guide you in these choices.
An orphan injury: iliotibial band syndrome is neglected by researchers
Attention physicians & therapists
This tutorial is written for both patients and professionals. It includes detailed analysis of recent research that you won’t find in any textbook, and the document is crafted to suit any skill level. For instance, user-friendly footnotes add an optional layer of detail. See my reading guide for professionals.
No wonder therapy often fails: iliotibial band syndrome is not studied enough,34 and treatment for it is not taught.5 I have a seemingly detailed modern sports injuries text on my shelf which offers only a couple of short sentences, concluding that “the prognosis is good with appropriate treatment”6 — without even saying what the treatment is!
I have suffered from IT band syndrome myself (see my own IT band story in Appendix B, below), and I have seen many stubborn cases of it in my own patients, so I know from both personal and professional experience that the prognosis for iliotibial band syndrome isn’t always good. Many people recover with a little rest and icing, but not everyone.
Is there a miracle cure for iliotibial band syndrome?
Of course not! Wouldn’t it be great if there were a proven treatment with minimal cost, inconvenience, or side effects? But medical science is nowhere close to this.
What I can do is explain and review all the options, help you to confirm your diagnosis, and debunk bad ideas. After reading this tutorial, some people — with a little effort — will finally enjoy a breakthrough, and get partial or complete relief of their symptoms, sometimes temporary, sometimes lasting. And maybe that is kind of miraculous!
With some effort and inconvenience, some people will achieve results that are sort of like a miracle.
Remember, chances are good that the therapists and doctors you’ve seen so far have not read what little scientific research has been published in the last few years. Even if they have, they probably haven’t studied it carefully. So how can they possibly advise you? Sure, their basic knowledge is fine for basic cases. But when you have a difficult case, you need better information. Or even if you just developed IT band syndrome for the first time recently, how long do you want to spend following poor quality advice? Get started on the right foot.
No, there are no miracle cures. But this tutorial will get you as close as you can get. Keep reading to find out exactly why most therapy fails. Overhaul your mental approach to the problem. And if you’ve spent a lot of time already trying to solve this problem … be shocked and amazed at how much time and money you’ve wasted on strategies that were probably always doomed to failure!
What would Adam & Jamie do? You know, if they were doctors?
How can you trust this information about iliotibial band syndrome?
I’m inspired by the MythBusters approach: I question everything and I have fun doing it. (No explosions, alas.) I assume that anything that sounds too good to be true probably is. I make no big promises, I do not claim to know the one true cause of anything, and I am not selling a treatment system or my own services. I say “I don’t know” when I don’t know and I say “I’m guessing” when I’m guessing. I actually read scientific journals, I clearly explain the science behind every key point (there are more than 90 footnotes here), and I link to the original sources so you can check them yourself. I hang out with doctors. I study harder than I ever did in school. Much harder.
Some of my favourite sources
I spend a lot of time on PubMed, and I cite from the best sources whenever possible, like The Cochrane Collaboration and The New England Journal of Medicine and PLoS Medicine.
![[Diagram showing the different primary pain locations for iliotibial band syndrome and patellofemoral pain syndrome.]](/resources/images/itbs-vs-pfps.jpg)
Front or side?
The epicentre of iliotibial band pain is always on the outside of the knee. The pain of patellofemoral pain syndrome is more variable, but usually dominates the kneecap.
A note about the “other” runner’s knee
Before we get started, it’s important to mention that ITBS is often confused with patellofemoral pain syndrome, the “other” runner’s knee injury. Although the two conditions can certainly seem quite similar, usually you can tell the difference just by the location of the pain.
Iliotibial band pain is truly a side of the knee condition, and the epicentre of the symptoms is always there, by definition.
On the other hand, if you have pain that definitely dominates the front of your knee, there’s a good chance that you have patellofemoral pain syndrome, and you should start reading the patellofemoral pain tutorial instead.
If you’re not sure which kind of knee pain you have, take the runner’s knee diagnosis test.
What causes iliotibial band syndrome?
In the next several sections, you will learn that this is not as easy a question to answer as you probably thought. In fact, it turns out that it’s not as easy as anyone thought. Overuse injuries of all kinds are proving to be hard to understand scientifically. Things that therapists and doctors used to consider “obvious” or “common sense” have turned out to be wrong, and researchers have only just begun to try to find out what’s really going on.
On the face of it, iliotibial band syndrome is still a simple condition, “obviously” caused by excessive knee usage and usually treated just by resting. But to anyone who can’t get rid of it just by resting, it is obvious that there must be more to it than that …
The conventional wisdom about iliotibial band syndrome
Iliotibial band syndrome is primarily known as a running injury, responsible for about one in twenty lower limb injuries in long-distance runners.7 But it is generally common: roughly one in twenty-five people engaged in other kinds of vigorous physical training will get a case of it.89 I estimate that as many as a quarter or half of all long-distance runners may get the condition eventually. Just to put this in perspective, iliotibial band syndrome is probably not much less common than ankle sprains, which are generally regarded as the single most common of all athletic injuries.10
Although primarily a runner’s affliction, iliotibial band syndrome is also prominent in cyclists11 — even though each stroke of the pedals is probably much less irritating to this knee condition than running is, sheer repetition can certainly make up for it. Hiking, backpacking and orienteering also cause the syndrome.12
The conventional wisdom says that iliotibial band syndrome (ITBS) is a kind of tendinitis, or at least an irritated tendon, anyway. The iliotibial band is a large tendon running down the side of the leg from the hip. If it gets too tight, it rubs painfully over a bump of bone on the side of the knee, the lateral epicondyle. For this reason, it is also commonly called iliotibial band friction syndrome (ITBFS).
Note: “iliotibial” is often mis-spelled as “ilotibial.”
Makes sense. Right? Well, not anymore. It turns out that iliotibial band friction syndrome is probably not a “friction” syndrome after all — not even a tendinitis, in fact. The irritated structure is probably not actually the iliotibial band! Nor is the IT band “too tight,” which particularly fascinates me, given that the world of physical therapy is pretty much obsessed with the tightness of IT bands!
Iliotibial band (friction) syndrome — not quite what you (or anyone) thought it was
In 2007, John Fairclough of University of Wales Institute, with seven coauthors, challenged the definition of iliotibial band syndrome, and even of the iliotibial band itself, in a paper published in the Journal of Science and Medicine in Sport.1314 They present a compelling analysis, concluding that “the perception of movement of the ITB across the epicondyle is an illusion,” in effect suggesting that the function, dysfunction and actual anatomy of the iliotibial band has been misunderstood and oversimplified for decades.15
“The perception of movement of the ITB across the epicondyle is an illusion.”
And as for the common wisdom that the iliotibial band is “too tight”?
In 2004, a research group at University of Connecticut led by Michelle Devan decided to try to figure out the effect of “structural abnormalities” on overuse knee injuries like iliotibial band syndrome.16 So they measured a bunch of stuff in a group of athletic young women, looking for structural problems that every therapist in the world “knows” are risk factors for various knee problems, including the tightness of iliotibial bands … and then they waited to see who got what kinds of knee injuries. Based on the conventional wisdom, you would fully expect the women with tight iliotibial bands to get more ITB syndrome.
In fact, it’s “obvious”!
But of course that’s not what happened! And that’s what makes IT band syndrome such an interesting subject. Now, here’s what did happen …
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Testimonials
Here are some of the nicest things that readers have said about my iliotibial band syndrome tutorial over the years. Thanks everyone!
Thanks for your great work. I’ve read about ITBS for years and everything I’ve ever read did not add up to ½ of the information you provided.
Kevin Burnett, runner, California
Sukey Jacobsen, Sukey Design Studio, Mount Vernon, Washington — fine art, tiles and functional art
Cortney Martin, PhD, Virginia Tech
Dr. Bryan Allf, MD, North Carolina
Rosemaree Gentles, recovered iliotibial band syndrome sufferer
Chris Taft, marathon runner, Easthampton, Massachusetts
One more special testimonial. In the Spring of 2009, I received an incredible endorsement from Jonathon Tomlinson, a GP in Hackney, East London, praising the whole website and every tutorial:
Dr. Jonathon Tomlinson, MBBS, DRCOG,MRCGP, MA, The Lawson Practice, London
High praise indeed! Thank you, Dr. Tomlinson — testimonials just don’t get much better than that.
Appendix A: My own iliotibial band syndrome story … grizzly bears included
(Where's Appendix A? It’s included in the full version of the document, and has some great stories about almost unbelievably silly misdiagnoses of iliotibial band syndrome.)
I was struck down dramatically by iliotibial band syndrome in both knees at once, on a solo backpacking trip in the Monashee Mountains in the spring of 1998. But that makes me sound more adventurous than I am.
The Monashee Mountains
This is where I got iliotibial band syndrome.
In reality, I am a big chicken, and being in the woods alone spooked me but good — I had never attempted solo backpacking before, and I never will again. I got injured because I was foolish and nervous. I pushed too hard, too fast, and ended up deep into the mountains late in the day, with the trail ahead lost in snow, and the trail behind too long to retrace before the fall of night.
I am a big chicken, and being in the woods alone spooked me but good!
I decided I wasn’t going to pitch a tent on the trail, and I would push to get back to the trail head even if I had to hike in the dark for a while. I practically ran down the mountain with a fifty pound backpack — big mistake! After just an hour, both my knees started to scream. I suppose it would have been smart to stop and camp, however dark and inhospitable the forest was, but my nervousness drove me onward.
The rest of the return hike was a nightmare. It certainly ranks as one of my most painful experiences. There were times when I felt certain I couldn’t take another step … yet somehow I did.
I was almost at the trailhead when the momma grizzly found me. I know she was a momma because I’d seen a warning sign about her before starting the hike. In fact, I was preternaturally alert for her presence as I neared the trailhead!
Unfortunately, alertness was pointless. It was deep twilight, and there was nowhere to run, and I couldn’t run anyway, and no one out runs a grizzly even on fresh legs. She charged me on the trail, and I heard her before I saw her.
I swear I thought the following two thoughts, in this order, and I have told this story exactly like this ever since it happened:
- I guess I’m going to be maimed and killed now. Damn. This is going to hurt.
- At least I won’t have to walk any further!
And that was all I had time for. Grizzlies are fast. She came at me like I was lying at the bottom of a cliff and she was falling on me. The idea of unlatching my bear spray from its “quick” release on my belt, pulling the safety pin, aiming, and firing … absolutely ridiculous! I think the reflex to reach for it didn’t kick in for about ten minutes. She was simply way too fast and intimidating.
She came at me like I was lying at the bottom of a cliff and she was falling on me.
And she did what grizzlies almost always do when they charge people: she veered off at the last second, leaving me trembling in my boots. I am eternally grateful, for the sake of my ego, that I somehow managed not to soil myself.
And that’s the very entertaining bear story! It’s given me years of dinner party storytelling material, and will for the rest of my life. Now, back to iliotibial band syndrome …
The next day, I quite literally could not get down stairs — which was problematic, because I lived in a 3rd-storey walk-up — both due to the worst case of delayed onset (post-exercise) muscle soreness I have had in my life, and the napalm attacks on the sides of my knees. I have seen some nasty cases of iliotibial band syndrome in my career, but I feel quite comfortable claiming that I’ve had it worse than anyone else I’ve ever met.
I was in school at that time, and we hadn’t learned diddly-squat about iliotibial band syndrome yet, nor did we later — that’s partly how I know just how poorly informed most massage therapists are about this condition. I never would have learned more than the most basic things about it if I hadn’t gotten the condition myself and been forced to learn more. Also, at that time I was only just beginning to learn about basic principles of rehabilitation. So, it took me one year to recover, and to this day I suffer occasional flare-ups.
I quite literally could not get down stairs — which was problematic, because I lived in a 3rd-storey walk-up.
That’s me, getting ready to flick the disc.
I am an enthusiastic ultimate player — that’s me there in the picture, getting ready to “flick” the disc — so the injury was deeply frustrating to me, and, just like every serious runner I’ve ever treated, it was nearly impossible to keep me from re-injuring myself. I simply would not stay off the field. Every return to play was premature. This was where I first made the observation that, in all likelihood, runners (and ultimate players) are more of a problem than their knees. Iliotibial band syndrome isn’t stubborn — we are!
For me, the magic bullets were probably rest, megadoses of icing, and the discovery that one of the taiqi moves I did was extremely good at stretching the iliotibial band and associated musculature (see Iliotibial Band Mobilization). How did I know? Because it hurt like hell! With my ultra-sensitive knees, it was really quite easy to evaluate how strongly different positions pulled on my iliotibial band — given that I was studying anatomy intensively at the time, I was in ideal circumstances to experiment. So this is how I first learned the importance of knee flexion in stretching the iliotibial band, a difference that was as clear to me as flicking a light switch: just add knee flexion to any of the standard stretches, and the iliotibial band pulls much tighter over the side of the knee.
All of this was good preparation for helping other people with iliotibial band syndrome, of course. Today, I feel like I know quite a few things that I really wish I had known when I first hurt myself! And that’s why this article exists.
Thanks to www.firstpeople.us for the grizzly bear photo!
What’s New In the Iliotibial Band Syndrome Tutorial?
This section provides a detailed record of significant changes to the ITBS tutorial. This document was originally published as a much simpler article in 2002. It was completely worked over and republished as a book-length tutorial in April of 2007. It is has been updated and revised regularly since then. In addition to being the most detailed ITBS information available anywhere, this document is also updated much more frequently than any other resource I have found.
Thursday, December 17, 2009 — Two massage sections significantly revised and expanded: IT band massage, foam rollers, and Graston Technique® and Trigger point therapy for ITBS.
Friday, November 20, 2009 — Substantive update today, a whole new section, Is patellar misalignment evidence of a tight IT band and iliotibial band syndrome? For a while, you can read it here for free.
Thursday, October 1, 2009 — Wow, that’s probably the longest I’ve gone without updating this tutorial! (I was quite preoccupied with upgrading the neck pain tutorial over the summer.) However, better late than never, a solid update: although brief in terms of wordage, I’ve just revised the section on anti-inflammatory medications to include Voltaren® Gel, an excellent treatment option for ITBS that only recently got into my radar. This update it is a freebie: you can read all about it in a free article as well as here in the tutorial.
Wednesday, July 1, 2009 — Major bibliography update. The SaveYourself.ca bibliography has long been the largest of its kind. It contains an incredible amount of surprisingly readable information about musculoskeletal health science, and it is now possible for visitors to search and sort the bibliography with powerful new features. For instance, every source about iliotibial band syndrome referenced in this tutorial can now easily be displayed in a single search, with a variety of options. See the front page for the announcement of the new features, or visit the bibliography itself.
Thursday, June 18, 2009 — New section: “Quick debunkery of several therapies that should be skeptical of.” Also did a little minor re-organizing of some content.
Wednesday, April 1, 2009 — The visual design of the site was upgraded over the past several days. Although this is not an update to the content of this tutorial, it is nevertheless a significant upgrade for all of them — like publishing new editions of books with better typesetting and layout. The new design is even cleaner and reader-friendly; it now looks that good in most web browsers; and pages load as much as 50% faster. Many under-the-hood improvements will make it much easier for me to improve tutorial content. The tutorials are now well-oiled machines of digital publishing goodness, vastly superior to the low-production values of most eBooks. More information about the upgrade is published on the front page.
Tuesday, March 17, 2009 — Added an important new evidence from a 2008 paper in American Journal of Sports Medicine showing that strengthening, stretching and coordination exercises are ineffective at preventing iliotibial band syndrome.
Tuesday, February 3, 2009 — Added a small new section about Traumeel, a popular but questionable remedy that I often get asked about. See the section, “Don’t bother with Traumeel,” or the free article, Does Traumeel Work?.
Saturday, January 17, 2009 — Corrected some minor abuse of a reference to some research about running speed. A reader pointed out that the study I’d cited (Orchard et al) had not involved any actual experiment related to running speed, as implied by my usage. The researchers I was quoting believed that slower running could be more stressful for the iliotibial band syndrome. They had some good reasons for this belief, but had not actually proven any such thing experimentally. Hat tip to Dan for pointing this out. A reminder to visitors and customers that constructive criticism is always welcome.
Monday, January 12, 2009 — A small but important cautionary warning added to one of the treatment recommendations. It had previously been presented as a harmless and hopefully helpful stretch, but a reader pointed out that it actually has a risk associated with it — hat tip to Alberto.
Saturday, November 29, 2008 — Minor update. Clarified a small but potentially vital point about the nature of the ITB “fat pad” for a reader who had been thrown off by my original wording. Discovering and correcting this sort of misunderstanding is one the best things about publishing in this format. If an author of a book expresses something in a way that misleads or confuses readers, there’s almost nothing that can be done about it!
Tuesday, November 18, 2008 — Major update! Today during a routine check for new research about ITBS I discovered a fascinating scientific paper about a new kind of surgical approach to ITBS. The new surgery is both an important new treatment option for patients, and an incredibly important proof of a principle about the nature of ITBS. Rather than upsetting any of the ideas in this tutorial (which has been known to happen), this new evidence strongly supports some of the most important ideas that I’ve been presenting here for several years now. So I’m quite excited! This is probably the biggest case I’ve ever had of new evidence really boosting an important point in one of my tutorials. For full details, you need to buy full access to the tutorial for USD$19.95 (or renew for much less, if you’re a past customer). There are now four new or significantly revised sections of the tutorial:
- So what’s actually inflamed?
- And why does that tissue get irritated in the first place?
- Could there be something wrong deeper inside the knee?
- A new surgical option: resection of the lateral synovial recess
Tuesday, October 21, 2008 — A minor update: added reader Franklin Swann’s experience with the benefit of a longer stride to the section, “Hot tip! Run less, but run fast,” along with a new analogy to help explain that phenomenon.
Thursday, July 3, 2008 — Supplemented the tutorial with a new short article about how Canadian Running Magazine botched their featured story about iliotibial band syndrome, and made a few corrections to the tutorial at the same time.
Thursday, June 5, 2008 — Added a reference to some expert opinion about IT band stretching.
Saturday, April 12, 2008 — Added information about Graston Technique® to the section “Deep longitudinal massage and Graston Technique® — a big fat waste of time and money.” Also added a reference to Kinesio Taping®, which seems popular right now.
Tuesday, January 22, 2008 — Added a new section, “Maybe you’re just not built for running.” This was inspired by some correspondence with a reader who’d been told this by her doctor. It led to some very good ways of explaining some of the core issues in ITBS mis-management.
Wednesday, January 16, 2008 — Introduced a new special offer: all ITBS tutorial customers now receive a second, companion tutorial at no charge, Save Yourself from Trigger Points & Myofascial Pain Syndrome! This is a really great deal, and a valuable extension to this tutorial. If you missed this bargain and want to be included, just drop me a line and I will happily grandfather you into the deal.
Wednesday, January 9, 2008 — Added a new concluding section to sum up the practical implications of all the detailed scientific information. Also, added some new information to the introduction to make sure that readers understand that there is no miracle cure for ITBS.
Thursday, October 18, 2007 — Added two more chilling mis-diagnosis tales: see “Another misdiagnosis story: the strange case of Ms. Strange” and “X-ray for iliotibial band syndrome? No!.”
Wednesday, October 3, 2007 — Responded to reader questions with some clarifications about “A much better iliotibial stretch.”
Saturday, July 21, 2007 — Upgraded the section “Hip abductor strengthening: is it really evidence-based?” to include new research findings.
Thursday, June 21, 2007 — Testimonials for this article reached a critical mass, recently, so I’ve added a permanent testimonials section — that is, it’s now included in the full version of the document as well as the sample, to continue the effort to include more and more reader-generated content.
Friday, June 8, 2007 — Added the section “What about the hips? Could hip pain be ITBS?” Expanded the “What’s the worst case scenario?” section, which now includes more reader reports of serious cases, and split part of it off to become an expanded “The risk of recurrence” section.
Sunday, May 27, 2007 — Integrated important new ideas inspired by the discovery of research by Devan, mostly in the section “ITBFS — not quite what you (or anyone) thought it was”
Thursday, May 24, 2007 — Added several clarifying details to the description of how to use the iliotibial band mobilization.
Tuesday, May 22, 2007 — Revision history implemented! Sorry I didn’t think of it sooner! Added section “ITBS vs. PFPS” to help readers determine the difference between iliotibial band syndrome and patellofemoral syndrome.
Acknowledgements
Thanks to Dr. Scott Dye for helping me to understand and believe in my own unconventional ideas about patellofemoral pain syndrome, and by extension every other joint problem … especially ITBS.
This document and all of SaveYourself.ca was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.
Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stores. Without you, all of this would be pointless.
And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Steven Novella, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.
Further Reading
If you found this article useful, you may also be interested in some other information I’ve published:
- SYStretching for Trigger Points — Is muscle knot release a good reason to stretch?
- SYQuite a Stretch — Stretching research clearly shows that a stretching habit isn’t good for warmup, injury prevention, preventing or treating muscle soreness, enhancing athletic performance … or even flexibility!
- SYThe Art of Rest — The finer points of resting for injury and pain rehabilitation
- SYMobilizing! — An alternative to stretching that “massages you with movement”
- SYProgressive Training — How to take “baby steps” to recovery from an injury or pain problem
- SYIcing for Injuries and Tendinitis — Become a cryotherapy master
- SYAlways Running the Same Way — The trouble with running on concrete and asphalt
- SYIliotibial band syndrome and patellofemoral pain syndrome aren’t as simple as they seem — Once again, evidence shows that you can’t blame overuse injuries on seemingly obvious structural problems
Notes
- For many years now, if you search with Google for “iliotibial band syndrome”, the website at the (or very near) the top of the list of results is the abominable “www.itbs.info” — an old and poorly constructed website by a well-intentioned amateur, with no good reason for being at the top of the list. There are no references, and his links to other reading are either broken or uninformative. I review that website more thoroughly and harshly in another article. There is not much improvement in the first few pages of Google’s search results: everything is basic, poorly written, or both. It’s just a mess! Return to text.
- As they are of most musculoskeletal problems.
Most doctors are well aware that there are serious shortcomings in the medical management of most musculoskeletal problems, especially chronic pain cases. Dr. Jonathon Tomlinson, an instructor at St. Leonards Hospital in Hoxton, explains that “undergraduate training is focused on hospital orthopedics (broken bones and anything else that’s amenable to surgery) or rheumatology (nasty inflammatory diseases) which comprise a minority of the aches/pains/strains and injuries that people actually suffer from.”
Medical researchers have done numerous studies showing that most doctors do not understand aches and pains. The Journal of Bone and Joint Surgery, and the Journal of the American Osteopathic Association, have both published papers recently showing that physicians simply do not have an adequate understanding of musculoskeletal medicine. In 2002, Freedman felt that “It is ... reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.” Then again in 2005 in JBJS, Matzkin concluded that “training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.” Most recently, in 2006, Stockard wrote “82% of allopathic graduates ... failed to demonstrate basic competency in musculoskeletal medicine.”
Return to text. - As of Jan 2009, only 125 search results in PubMed! Compare that to 4200 for adhesive capsulitis (frozen shoulder), or 6900 for carpal tunnel syndrome. Also, more so in the case of iliotibial band syndrome than other conditions, a great number of those papers are tutorial papers, not primary research. To an amazing degree, they all tend to repeat conventional wisdom and reference each other and clinical experience instead of actual science. Return to text.
- Ellis et al. Manual Therapy. 2007. This 2007 scientific review paper makes it extremely clear that there is a “paucity in quantity and quality of research” about iliotibial band syndrome. They also conclude that what information exists is not particularly helpful! “There seems limited evidence to suggest that the conservative treatments that have been studied offer any significant benefit in the management of ITBFS.” Yet it is absolutely routine for therapists and doctors, and even so-called experts, to make claims of therapeutic effectiveness! What are they basing that optimism on? The truth is, they simply don’t really know what they are talking about. They can’t — no one does! Return to text.
- In my own 3000 hours of training — three full years of nothing but studying aches and pains and how to treat them — it was barely discussed. Unless a massage therapist has gone out of his or her way to study the condition, he or she knows no more than anyone else who spends twenty minutes looking it up on the internet … and perhaps less! Return to text.
- This is not a joke. It’s a good, new sports injury text book — but its inadequate coverage of ITB syndrome is typical for the subject. The text is Clinical guide to sports injuries. Return to text.
- Sutker et al. Sports Med. 1985. Return to text.
- Almeida SA, Williams KM, Shaffer RA, Brodine SK. Epidemiological patterns of musculoskeletal injuries and physical training. Med Sci Sports Exerc. 1999 Aug;31(8):1176-82, abstract. In a study of almost 1300 Marine recruits in training, “the most frequent site of injury was the ankle/foot region (34.3% of injuries), followed by the knee (28.1%). Ankle sprains (6.2%, N = 1,143), iliotibial band syndrome (5.3%, N = 1,143), and stress fractures (4.0%, N = 1,296) were the most common diagnoses. The findings also suggest that “[vigorous] training, particularly running, and abrupt increases in training volume may further contribute to injury risk.” Return to text.
- In Clinical guide to sports injuries, on p340, iliotibial band syndrome is listed as a “less common” cause of knee pain, after the “most common” conditions of patellofemoral syndrome, patellar and quadriceps tendinopathy, meniscus injuries and knee instability … all of which contradicts my own experience. I have seen more iliotibial band syndrome in my practice than all of those other “more common” conditions combined. This may reflect the nature of my practice more than reality for the rest of the world, but I’m just sayin’. Return to text.
- This is surprisingly hard to prove, because the vast majority of ankle sprains are minor and go unreported and untreated. However, clinical experience and many years of personal experience playing ultimate (a Frisbee team sport with an intensity like soccer) indicates that ankle sprains are probably more common than any other significant injury. Return to text.
- Some papers that mention cycling: Ellis, Fairclough, Fredericson, Martens, Farrell. Return to text.
- Linde. British Journal of Sports Medicine. 1986. From the abstract: “Medial shin pain, Achilles peritendinitis, peroneal tenosynovitis and iliotibial band friction syndrome were the most frequent overuse injuries [in 42 orienteers].” Return to text.
- Fairclough et al. “The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome.” Journal of Anatomy. 2006. Full Abstract:
Iliotibial band (ITB) syndrome is a common overuse injury in runners and cyclists. It is regarded as a friction syndrome where the ITB rubs against (and 'rolls over') the lateral femoral epicondyle. Here, we re-evaluate the clinical anatomy of the region to challenge the view that the ITB moves antero-posteriorly over the epicondyle. Gross anatomical and microscopical studies were conducted on the distal portion of the ITB in 15 cadavers. This was complemented by magnetic resonance (MR) imaging of six asymptomatic volunteers and studies of two athletes with acute ITB syndrome. In all cadavers, the ITB was anchored to the distal femur by fibrous strands, associated with a layer of richly innervated and vascularized fat. In no cadaver, volunteer or patient was a bursa seen. The MR scans showed that the ITB was compressed against the epicondyle at 30 degrees of knee flexion as a consequence of tibial internal rotation, but moved laterally in extension. MR signal changes in the patients with ITB syndrome were present in the region occupied by fat, deep to the ITB. The ITB is prevented from rolling over the epicondyle by its femoral anchorage and because it is a part of the fascia lata. We suggest that it creates the illusion of movement, because of changing tension in its anterior and posterior fibres during knee flexion. Thus, on anatomical grounds, ITB overuse injuries may be more likely to be associated with fat compression beneath the tract, rather than with repetitive friction as the knee flexes and extends.
Return to text. - Fairclough et al. “Is iliotibial band syndrome really a friction syndrome?” Journal of Science & Medicine in Sport. 2007. Full Abstract:
Iliotibial band (ITB) syndrome is regarded as an overuse injury, common in runners and cyclists. It is believed to be associated with excessive friction between the tract and the lateral femoral epicondyle-friction which 'inflames' the tract or a bursa. This article highlights evidence which challenges these views. Basic anatomical principles of the ITB have been overlooked: (a) it is not a discrete structure, but a thickened part of the fascia lata which envelops the thigh, (b) it is connected to the linea aspera by an intermuscular septum and to the supracondylar region of the femur (including the epicondyle) by coarse, fibrous bands (which are not pathological adhesions) that are clearly visible by dissection or MRI and (c) a bursa is rarely present, but may be mistaken for the lateral recess of the knee. We would thus suggest that the ITB cannot create frictional forces by moving forwards and backwards over the epicondyle during flexion and extension of the knee. The perception of movement of the ITB across the epicondyle is an illusion because of changing tension in its anterior and posterior fibres. Nevertheless, slight medial-lateral movement is possible and we propose that ITB syndrome is caused by increased compression of a highly vascularised and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle. Our view is that ITB syndrome is related to impaired function of the hip musculature and that its resolution can only be properly achieved when the biomechanics of hip muscle function are properly addressed.
Return to text. - This is a wonderful example of how primitive medical science still is. Can we really still be learning basic anatomy in 2007? We can! To be fair to anatomists, they probably have understood the details of iliotibial band anatomy for a long time — it just hadn’t reached clinicians. Or even medical researchers, unfortunately. Return to text.
- Devan et al. Journal of Athletic Training. 2004. For a more detailed analysis of this research, see Iliotibial band syndrome and patellofemoral pain syndrome aren’t as simple as they seem. Return to text.
