I made a new furry friend the day I was struck down with severe iliotibial band syndrome. (Thanks to www.firstpeople.us for the photo.)

Note: this is the condensed version of this story. If you find me particularly amusing, you can also read a more long-winded version.

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.

In reality, I am a big chicken, and being in the woods alone spooked me but good. I got injured because I pushed too hard, too fast, and ended up deep into the mountains late in the day, with the trail ahead lost in snow. I decided to rush back to the trail head even if I had to hike in the dark for a while. So I practically ran down the mountain with a fifty pound backpack — big mistake! After just an hour, both my knees started to scream.

The rest of the hike was a nightmare, certainly ranking as one of my most painful experiences. There were times when I felt certain I couldn’t take another step … yet somehow I did.

The Monashee Mountains

This is where I got iliotibial band syndrome.

The Monashee Mountains

This is where I got iliotibial band syndrome.

I was almost at the trailhead when a momma grizzly found me. I’d seen a warning sign about her before starting the hike. In fact, I had gotten quite paranoid about crossing paths with her as I neared the trailhead!

It didn’t work.

It was deep twilight, and there was nowhere to run, and I couldn’t run anyway, and no one out runs a grizzly anyway. She charged me on the trail, and I heard her before I saw her. I thought the following two thoughts, in this order, I swear:

1. I guess I’m going to be maimed and killed now. Damn. This is going to hurt.
2. At least I won’t have to walk any further!

Grizzlies are fast! (Up to 34 mph, 55 kph.) 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, pulling the safety pin, aiming, and firing … absolutely ridiculous! She was simply way too fast and intimidating.

And she did what grizzlies almost always do when they charge people: she veered off at the last second. Grizzlies aren’t particularly predatory, but they certainly take their cubs seriously, and her main goal was to intimidate me … and that she surely did.

And that’s my entertaining bear story! It’s given me years of dinner party material, and it 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 basics if I hadn’t been forced to learn more by my own injury. It took me one year to recover, and to this day I still suffer occasional flare-ups if I run for more than a couple hours … which I do.

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 best treatments were probably rest, megadoses of well-timed icing (controlling inflammation at the times when it was most likely to start), and the discovery that one of the taiqi moves I did was particularly 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. To this day, I don’t know if the stretching actually helped, but it certainly felt like a “real” stretch of the IT band, more so than any other stretch I could do.

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 very, very long tutorial exists.

return to introduction

Thank you to Dr. Michels and his colleagues for their important, evidence-inspired work in pioneering a new surgical treatment for ITBS, with its fascinating implications. Thank you as well to Dr. Fairclough and his research colleagues who also deserve special mention for their seminal 2007 paper on IT band syndrome, which was a game-changer and instantly made this topic much more interesting to continue writing about.

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.

Warm thanks also to reader John J, who reported more typografic errors and other miner glitches in onelarge batch than I would ever have dreamed posssible so many years into the lyfe of this document. Many readers have helped out with such reporting, but John’s effort was truly the most remarkable yet.

Here is what some readers have said about the iliotibial band syndrome tutorial over the years. Feedback is always welcome. I focus on the positive in this section, but I want to acknowledge that I certainly do receive some criticisms as well. In many cases I respond by making improvements to the tutorial. However, the vast majority of feedback is enthusiastic. Thanks, everyone!

I owe you many thanks. Your tutorial has given me great hope. I was extremely discouraged and frustrated by the issues I was having, but I experienced more relief in my first session with a trigger point therapist than I did in 12 weeks of physical therapy.

— Ryan Luke, MA, CSCS, Department of Kinesiology and Health, Georgia State University

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

I appreciate your research on this subject, and that you have clearly debunked lots of poor quality “science.”

— Sukey Jacobsen, Sukey Design Studio, Mount Vernon, Washington — fine art, tiles and functional art

When investigating my IT band injury online, the information I found was superficial. That changed when I came upon your well-researched report. I teach scientific writing as part of my class and as I read your report I kept thinking that I'd love for my students to read it and see that well-researched work can be fun to write and read as well. Your plan is the only one I have seen based on peer-reviewed research, evidence, and professional and personal experience. No doubt, it'll take a healthy dose of patience, self-restraint, diligence, and positive attitude on my part, but what you wrote and the runner testimonials showed me that ITB injuries are not something to mess around with. Thanks for the great work, Paul!

— Cortney Martin, PhD, Virginia Tech

I really appreciate your objectivity.

— Dr. Bryan Allf, MD, North Carolina

On May 21st, 2008, Dr. M. Gilbart released my IT band and now all is well. This is 2 years and 5 months after the first diagnosis. Thank you again for all your encouragement. I re-read your iliotibial band syndrome tutorial several times over the last few months, and each time I found new nuggets of advice.

— Rosemaree Gentles, recovered iliotibial band syndrome sufferer

Read 15 more comments

One more special comment. 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:

I'm writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— 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.

If you found this article useful, you may also be interested in some other information I’ve published:

• SY Stretching for Trigger Points — Is muscle knot release a good reason to stretch?
• SY Quite a Stretch — Stretching research clearly shows that a stretching habit isn’t good for much of anything that people think it is
• SY The Art of Rest — The finer points of resting for injury & pain rehabilitation (hint: it’s a bit trickier than you might think)
• SY Mobilize! — Dynamic joint mobility drills are an alternative to stretching that “massages you with movement”
• SY Progressive Training — How to take “baby steps” to recovery from an injury or pain problem
• SY Icing for Injuries, Tendinitis and Inflammation — Become a cryotherapy master
• SY Always Running the Same Way — The trouble with running on concrete and asphalt
• SY Iliotibial 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

This document was originally published as a much simpler article in 2002. It was expanded and republished as a book-length tutorial in April of 2007, and has been updated and revised regularly since then.

A major feature of my tutorials is that I actively update them as new science and information becomes available. Unlike regular books, and even ebooks — which can be obsolete by the time they are published, and can go years between editions — this tutorial is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 35 major and minor updates worth logging since I started logging carefully in late 2009, and countless more minor tweaks and touch-ups.

Rewritten (Jan 23 '12, section #37) — Major changes: new science, new recommendations, more detail, and some explanation of the (very difficult) problem of why anti-inflammatory injections might work despite the fact that IT band syndrome doesn’t involve much inflammation. See section #37, Steroid injections: a complicated mix of certain risks and uncertain rewards: What can you do about iliotibial band syndrome?

Rewritten (Jan 16 '12, section #41) — Completely revised to reflect new science and new understanding of the interaction of ice with “inflammation.” See section #41, The potential of power icing: What can you do about iliotibial band syndrome?

Rewritten (Jan 16 '12, section #40) — Completely revised to reflect new science and new understanding of the interaction of NSAIDs with “inflammation.” See section #40, Ibuprofen and friends: non-steroidal anti-inflammatory medications (NSAIDs), especially Voltaren® Gel: What can you do about iliotibial band syndrome?

Major Update (Jan 13 '12, section #36) — Expanded and revised summary of treatment options, with emphasis on new and better recommendations about “anti-inflammatory” treatments. See section #36, Treatment: What can you do about iliotibial band syndrome?

Updated (Jan 11 '12, section #35) — Advice on “running through” has changed, with more emphasis on the unknown but plausible risk of permanent damage. See section #35, Can you “run through” iliotibial band syndrome?: What’s the worst case scenario for iliotibial band syndrome?

Major revision (Jan 11 '12, section #18) — Extensive editing and re-writing concerning the nature of inflammation. The main point of the section remains unchanged, but the section now does a much better job of explaining why ITBS isn’t really inflamed, and why it matters. Although not cited, this update drew heavily on some new scientific papers. See section #18, The inflammation myth: is anything even “inflamed” in the first place?: What causes iliotibial band syndrome?

Updated (Dec 29 '11, section #39) — Added new information and some pie charts about the success rate of arthroscopic surgery for ITBS. See section #39, The new surgery: excision of tissue from under the IT band: What can you do about iliotibial band syndrome?

Minor update (Dec 13 '11, section #43) — Addressed some common fears about the threat of getting out of shape while resting. See section #43, The art and science of resting: What can you do about iliotibial band syndrome?

Trivial update (Nov 25 '11, section #5) — Added an example of unusually bad ITBS information, made widely available. See section #5, How can you trust this information about iliotibial band syndrome?

Major update (Nov 23 '11, section #5) — Clearer and more thorough content throughout several sections about the “Nature of the Beast” and “Diagnosis,” especially from the discussion of root causes and onwards. I am producing the audio version of this tutorial, and I am revising and improving content significantly as I go. Information about trigger points was completely re-written, and there’s a whole new section about hip and thigh pain. See section #5, How can you trust this information about iliotibial band syndrome?

Updated (Nov 16 '11, section #54) — Modernization and revision for clarity. See section #54, Mobilize and stretch the hip musculature: What can you do about iliotibial band syndrome?

New section (Nov 16 '11, section #52) — Stretching is such a hot topic that I decided to break the discussion up with a new section focussed on stretching the IT band itself. It was inspired by important new scientific evidence: researchers have found that IT band stretching is not a very moving experience… See section #52, The trouble with stretching the IT band in particular: What can you do about iliotibial band syndrome?

Major update (Nov 15 '11, section #53) — Significant modernization and clarifications. Much better description of why this kind of stretch might be worth trying. See section #53, Some stretching hope: a better iliotibial stretch?: What can you do about iliotibial band syndrome?

New science (Nov 15 '11, section #10) — Added more anatomical evidence that the IT band is particularly impossible to stretch or even move. See section #10, You and your iliotibial band: so is it a tendon or what?: What causes iliotibial band syndrome?

New section (Nov 10 '11, section #20) — No notes. Just a new section. See section #20, Most hip and thigh pain does not have much to do with IT band syndrome: What causes iliotibial band syndrome?

Minor update (Nov 10 '11, section #6) — Clarifications about the location of IT band syndrome pain. See section #6, A note about the “other” runner’s knee.

Updated (Nov 2 '11, section #51) — Added new research evidence that stretching doesn’t prevent injuries, including (of course) ITBS. See section #51, Stretching to prevent or treat IT band syndrome: What can you do about iliotibial band syndrome?

New video (Oct 14 '11, section #2) — Section now includes a new video, summarizing myths and treatment mistakes. See section #2, Unfortunately, ineffective therapies for IT Band syndrome are everywhere.

Minor update (Sep 28 '11, section #58) — Added reference to Kong et al, about the effect of shoe wear. See section #58, Running softly and the impact of impact: What can you do about iliotibial band syndrome?

Minor update (Jul 29 '11, section #1) — Added a reference about the poor overall quality of online information about common injuries. See Starman. See section #1, Introduction.

Rewritten (Jun 17 '11, section #58) — Evidence about the real but surprisingly weak connection between impact forces and injury from Zadpoor et al has prompted a bunch of revision and new recommendations for runners. See section #58, Running softly and the impact of impact: What can you do about iliotibial band syndrome?

Major update (Jun 15 '11, section #58) — Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really be cleaned up in general, paving the way for efficient conversion to other formats (Kindle, Apple’s iBookstore, etc). Best of all, it is now significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement. See section #58, Running softly and the impact of impact: What can you do about iliotibial band syndrome?

New section (Apr 28 '11, section #48) — No notes. Just a new section. See section #48, Mis-treatment horror story: intense massage on an obviously inflamed thigh: What can you do about iliotibial band syndrome?

New section (Feb 20 '11, section #57) — Finally, long overdue, a new section on this topic. See section #57, Should you run naked? On faddish running styles and running shoes (or the lack thereof): What can you do about iliotibial band syndrome?

Important new info (Feb 8 '11, section #57) — Where’s the fire? Recently I published a major new article about repetitive strain injuries (like ITBS), in which I explain that these injuries are rarely actually inflamed. Instead of being “on fire,” excessively stressed tissues tend to break down without inflammation — a kind of rot. For the full scoop on inflammation and repetitive strain injuries, see: Repetitive Strain Injuries Tutorial: Five surprising and important facts about repetitive strain injuries like carpal tunnel syndrome, tendinitis, or iliotibial band syndrome. See section #57, Should you run naked? On faddish running styles and running shoes (or the lack thereof): What can you do about iliotibial band syndrome?

New section (Dec 2 '10, section #31) — New short section for both this book and the patellofemoral pain book covering potentially confusing alternative diagnoses, such as politeal artery entrapment syndrome (PAES). See section #31, Other possible diagnoses and sources of diagnostic confusion: How do you know you’ve got iliotibial band syndrome?

Overhauled (Sep 15 '10, section #14) — Rewrote section to accommodate some new science. The new evidence is interesting, but not particularly illuminating: it mostly just emphasizes how we really (still) don’t know if IT band tightness is actually a problem. See section #14, And why does that tissue get irritated in the first place? Is it the tightness?: What causes iliotibial band syndrome?

New cover (Aug 6 '10, section #14) — At last! This e-book finally has a “cover.” SHOW See section #14, And why does that tissue get irritated in the first place? Is it the tightness?: What causes iliotibial band syndrome?

Minor update (Jul 27 '10, section #61) — Updated the nutraceuticals item with information about a new study of glucosamine for knee pain. See section #61, Brief debunkery of several therapies that you should be skeptical of: What can you do about iliotibial band syndrome?

New section (Feb 12 '10, section #65) — One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). See section #65, Appendix B: List of surgeons offering arthroscopic repair of iliotibial band syndrome: Some summary of what to actually do with all of the above.

New section (Feb 12 '10, section #39) — One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). See section #39, The new surgery: excision of tissue from under the IT band: What can you do about iliotibial band syndrome?

Major update (Feb 12 '10, section #38) — One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). See section #38, The old surgery: snipping the band: What can you do about iliotibial band syndrome?

New section (Feb 12 '10, section #13) — One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). See section #13, So is ITBS a bursitis?: What causes iliotibial band syndrome?

Major update (Feb 12 '10, section #12) — One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). See section #12, A new surgical procedure shows that you can fix IT band syndrome without loosening the IT band: What causes iliotibial band syndrome?

Major update (Feb 12 '10, section #11) — One of several new/revised sections based on the implications of a new surgical technique (see Michels et al). See section #11, So what’s actually irritated? Definitely not the IT band …: What causes iliotibial band syndrome?

And many more (May '07 – Dec '09) — Thirty-five older updates are listed in a separate document, for anyone who cares to take a look.

1. 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!
   
   And that opinion is backed up by experts: In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. BACK TO TEXT
2. The muscles that actually control the tension on the iliotibial band, such as the tensor fascia latae and gluteus maximus. BACK TO TEXT
3. 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 many studies showing that most doctors do not understand aches and pains or heed expert recommendations. A good recent example is a paper in the Archives of Internal Medicine showing that family doctors frequently ignore guidelines for the care of low back pain — see Williams et al.

   More generally, 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 et al felt that “It is ... reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.” Then again in 2005 in JBJS, Matzkin et al concluded that “training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.” Most recently, in 2006, Stockard et al wrote “82% of allopathic graduates ... failed to demonstrate basic competency in musculoskeletal medicine.”

   BACK TO TEXT
4. Quadriceps strengthening is a conventional treatment of dubious value for patellofemoral pain syndrome. Although strengthening some muscles (hip and gluteals) has been proposed as a treatment for ITBS, quadriceps training is not even really on the table as an option. I assume that it gets prescribed anyway simply because these two knee pain conditions are often confused — a simple case of mistaken identity. BACK TO TEXT
5. 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. BACK TO TEXT
6. Ellis et al. Iliotibial band friction syndrome — A systematic review. Manual Therapy. 2007. PubMed #17208506. Comments: 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! BACK TO TEXT
7. 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! BACK TO TEXT
8. 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. BACK TO TEXT
9. Falvey et al. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scandinavian Journal of Medicine & Science in Sports. 2010. PubMed #19706004. “Our results challenge the reasoning behind a number of accepted means of treating ITBS.” BACK TO TEXT
10. A while ago I noticed that a new book about iliotibial band syndrome had appeared on Amazon, The Official Patient's Sourcebook on Iliotibial Band Syndrome. I made a note to myself read it, and hopefully learn something — had someone finally written something that might compete with this tutorial? When I returned recently to buy it, I found the following review:

    Complete ripoff. This is not a book about Iliotibial Band Syndrome, even tho the title would lead you to believe it is. The book contains a few sentences about IBS, and then chapter after chapter of boilerplate about things like how to find a doctor, or how to research nutrition, how to use a library. I am astonished that the publishers had the gall to publish such a ripoff.

    I didn’t waste my money verifying this: the world is already awash in scammy, useless information about this problem and all the others. I have no doubt the “book” is just as empty and pointless as the reviewer says it is. BACK TO TEXT
11. Sutker et al. Iliotibial band syndrome in distance runners. Sports Med. 1985. BACK TO TEXT
12. Almeida et al. Epidemiological patterns of musculoskeletal injuries and physical training. Medicine & Science in Sports & Exercise. 1999. Comments: 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.” BACK TO TEXT
13. 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’. BACK TO TEXT
14. 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. BACK TO TEXT
15. Some papers that mention cycling: Ellis, Fairclough, Fredericson, Martens, Farrell. BACK TO TEXT
16. Linde. Injuries in orienteering. British Journal of Sports Medicine. 1986. Comments: From the abstract: “Medial shin pain, Achilles peritendinitis, peroneal tenosynovitis and iliotibial band friction syndrome were the most frequent overuse injuries [in 42 orienteers].” BACK TO TEXT
17. 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. PubMed #16533314. 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.

    BACK TO TEXT
18. Fairclough et al. Is iliotibial band syndrome really a friction syndrome?. Journal of Science & Medicine in Sport. 2007. PubMed #16996312. 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.

    BACK TO TEXT
19. 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. BACK TO TEXT
20. Devan et al. A Prospective Study of Overuse Knee Injuries Among Female Athletes With Muscle Imbalances and Structural Abnormalities. Journal of Athletic Training. 2004. PubMed #15496997. For a more detailed analysis of this research, see Iliotibial band syndrome and patellofemoral pain syndrome aren’t as simple as they seem. BACK TO TEXT

There are 100 more footnotes in the full version of this book.
I like footnotes, and I try to have fun with them.

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