ITB Syndrome of the Knee

Hello and welcome back to the ThreeSpires Physiotherapy blog where we take a look at all things physiotherapy and health related. Over the last few blogs we have been taking a deep dive into the knee, its structures and how they can be injured. I thought that we should finish our series on the knee by looking at an extremely difficult to deal with condition that affects the knee and particularly runners: ITB Syndrome. So, I think that before considering the causes and treatments of ITB Syndrome we need first of all to understand what the ITB is.

The Iliotibial Band (ITB)

The Iliotibial band (ITB) is a large piece of connective tissue that runs down the outside of the leg from the hip/pelvis to the knee and shin. In the image you can clearly see that the ITB is the thick band of tissue that runs down the outside of the leg. It is connected to the hip and pelvis by tensor fascia latae and is a thickened continuation of fascia lata which is the deep fascia of the thigh which encircles all of the muscles of the thigh. These connections from the top of the hip and pelvis through to the shin and also around the whole of the thigh via fascia lata give it a wide range of roles and puts the ITB under a large amount of stress.

What Does the ITB Do?

In simple terms the ITB provides a stabilising connection all the way from the pelvis down through the thigh and into the shin and knee. It helps stabilise the knee through gait and the actions of walking and running and as such comes under large loads at times. In reality though its actions are fairly complex and still an area of active research which is why ITB Syndrome is such a tricky condition to sort out.

What are the Symptoms of ITB Syndrome?

Although actually treating and getting rid of ITB Syndrome can be difficult the actual symptoms of ITB Syndrome are fairly easy to recognise and diagnose:

• Pain on the outside of the knee.  This is most usually a dull ache that worsens with running and initially at least can seem very minor. Often the patient will not be able to remember a clear event where it went, rather they will be able to describe a slight niggle on the outside of their knee that has progressively worsened over several runs. If the patient has continued to run through this pain they may well be getting some occasional sharp pain and be struggling to walk without a limp.

An important point to note is that these could be the symptoms of quite a few other conditions and not just ITB Syndrome and it is important that you get it confirmed by a professional (such as a physiotherapist) that you actually do have ITB Syndrome.

What Causes ITB Syndrome?

I think is fairly well accepted that ITB Syndrome comes under the heading of an overuse injury and is similar in causes in may regards to “runner’s knee” or patella-femoral pain that we have covered in the past. There is very rarely any element of trauma and often the patient will struggle to clearly identify when it began but they know it is getting worse. A quick word of warning about causes of ITB Syndrome, it is still even after all this time an active area of research and although overuse and overload is the primary mechanism there is a large amount of debate and research about how much other factors contribute to it. As such below I have described the most commonly accepted causes or situations in which ITB Syndrome tends to occur but other physiotherapists may have different ideas about the importance of each factor:

Going too Far or too Fast: for many of the other factors that can cause ITB Syndrome it is reasonable to accept that there can be a healthy amount of discussion and differences of opinion. However going too far or too fast and overloading the ITB is quite clearly the principal reason for the majority of ITB Syndrome. New runners or runners returning after a long break are especially prone to falling foul of this. I know I personally have done this despite being aware of the risks!  If you build up both distance and speed  too quickly then areas such as the ITB can become overloaded. Structures such as the ITB which have low blood supply take a much longer period of time to strengthen and adapt to new stimuli than most people are aware of.

Hip weakness: counterintuitively a large part of the control of the knee and the lower limb comes specifically from the muscles at the hip with the hip muscles themselves being responsible for control of internal and external rotation of the majority of the leg. So strangely a strength deficit here can cause a structure lower down the kinetic chain to become overloaded such as the knee or in this case the ITB. Certainly, as a physiotherapist if I see that a patient's knee is moving inwards on walking, squatting or running then I would certainly want to assess their hip strength to see how much it is likely to be contributing to their ITB Syndrome. Strengthening of the hip muscles in patients with ITB Syndrome can produce good results in terms of improved control, gait and reduced pain.

General Leg Strength: as mentioned above weakness in one area can cause problems in another. Sometimes there can be a significant difference in strength between legs which can cause the ITB to become overloaded. This can either be on the weak side because the leg is unable to be controlled well enough through gait and therefore the ITB becomes overloaded or it can be on the strong side because this side is doing more work and taking more load in order to compensate for the weak side.

I think that the first three potential causes of ITB syndrome are reasonably well accepted by most clinicians even though we might debate the priority that should be given to each.  However for the next set of potential causes of ITB Syndrome there is substantial debate around how much each one contributes and if it is even important. However, as a physiotherapist I think it is important to look at all aspects of patients when assessing ITB symptoms and therefore eliminate potential underlying causes of problems. So, I tend to examine the following issues in patients but focus less on them than the first three.

Leg length discrepancy: Variations in the length of each leg in individuals has been thought to be a cause of many running ailments such as patella-femoral pain syndrome (form more detail click here) and there are many clinicians who believe it to be an underlying cause of many overload syndromes such as ITB Syndrome.  Differences between the length of each leg in most people are common and my own experience is that most people will have a visible difference. Certainly, the majority of people will have a difference of at least 5-10 mms between sides and have no problems and in fact be completely unaware of this difference. The likely importance as a contributing factor towards ITB Syndrome of leg length discrepancy increases with the size of the difference and the amount of running or weight-bearing activity someone is doing. Potentially (but as with everything not always!) a person doing a lot of running or a large amount of walking might find that a difference of over 10mms gives them issues but with all the factors such as leg strength and going too far etc also likely to be contributing it would be very difficult to be certain about the effect of leg length.  To be fair though anything over 20 mms would in my opinion need to be addressed and would most likely be immediately and quickly visible. The reasons that this potentially causes ITB Syndrome are easy to understand: if you have a shorter leg it is very likely that one leg (most likely the shorter) will take more load and more impact. This difference in load will not be felt when walking normally but the further you walk or the longer you run the more this adds up.

Foot Posture: by this I mean whether someone has flat feet or high arches or some other variant of foot mechanics. This potential contributing factor to ITB Syndrome has been the target of significant amounts of research. However, I think that even those who believe it to be a significant factor would accept that most of the research has been inconclusive and it is difficult to say how much of a factor foot posture truly plays in the likelihood of developing ITB Syndrome. This is not to say that foot shape and posture does not play a role in developing ITB Syndrome in some people (in my opinion it does) but that instead you should address the more obvious issues such as overload and hip weakness first before considering foot posture. That having been said, some people have well developed medial arches of the feet and others have very flat feet, sometimes when walking or running those with flat feet can display quite a clear over-pronation at the ankle and foot which in turn clearly deviates the knee. There is a good argument to be made that this in turn then overloads the knee through gait and can cause ITB Syndrome. As I said there is a large amount of debate on this topic but certainly my experience is that for some patients with very flat feet and who are heavily pronating in their gait a medial arch support orthotic can produce good results in reducing pain and allowing patients to return to running.

Ankle Instability: the stability and strength of each of the joints in the leg is clearly going to affect the load through the other joints or potentially the joints on the opposite side. As such ankle instability can sometimes cause an overload of the knee joint. I would say that in my experience this is less common than the other issues identified earlier but still occasionally I see some patients who have a normal medial arch but have an unstable ankle on one side. This can cause them to overload the structures of the knee when running and lead to patella-femoral pain. With these patients some balance work and ankle proprioception exercises tends to work well in eliminating their ITB Syndrome.

Who is at Risk of ITB Syndrome?

As discussed in all of our other blogs about knee pain and its causes pretty much anyone with a knee can injure their ITB but there are some factors that make developing ITB Syndrome more likely.

• Runners: this group probably account for the vast majority of people who develop ITB Syndrome as this group is highly prone to putting large loads through their ITB and overloading it. Anyone who does a large amount of running or especially those who have either taken up running recently or have started training for a specific event are at risk of developing ITB Syndrome. In no way does this mean that all runners will develop ITB Syndrome or that ITB Syndrome is an inevitable consequence of running but there is a fairly clear linkage between runners and development of ITB Syndrome. Runners most likely to be at risk of ITB Syndrome are those who have been rapidly increasing distance or speed recently.
• Walkers: obviously most people walk to some degree but in this case here I am considering people whose hobby is walking long distances or walking in the hills. Again as with running doing a lot of hill or mountain walking does not mean that you are going to develop ITB Syndrome if this is something that you have been doing for a long time. Those most at risk here are those who have recently started and are rapidly building up the distances that they walk.

How is ITB Syndrome Diagnosed?

Most usually ITB Syndrome knee will be diagnosed through a combination of symptoms and a physical assessment by a physiotherapist, as most people will realise that their GP is unlikely to be the best person to contact for this issue. Sometimes patients will have initially gone to their GP with knee pain and then been referred on to a physiotherapist. The physio at this point will take a full history, do a physical assessment and based on the combination of these factors make a diagnosis of ITB Syndrome. As with most sporting injuries It is best to get an early diagnosis of ITB Syndrome as this allows the best management and treatment plan to be devised and for you to get back to your activity as soon as possible. Delaying a diagnosis and letting things worsen will only lengthen the rehab process needed for your ITB.

Treatment for ITB Syndrome

In general, most ITB pain will respond to a slow return to activity and exercises designed to strengthen the ITB. Occasionally there is a need for more aggressive options such as surgery but this is not common. Below I have tried to cover the most usual options for helping with ITB Syndrome

1. Early Assessment & Diagnosis: I put this part in most of my blogs about injuries and I know that for many people reading they will be thinking that this sounds like common sense and hardly part of treatment. However, in my experience this is at least initially the most important thing you can do to help with your ITB Syndrome and knee pain. Before thinking about the best treatment and what is the best strategy to recover you need to know exactly what the issue is and get some advice on what to do next. By having an early assessment and getting a clear diagnosis you can be confident about what you are dealing with and then choose the best treatment options.
2. Rest: as with my previous treatment option for ITB Syndrome I can hear many people complaining that rest is not actually a treatment. However, in my opinion in the initial period (certainly the first week) the best option to help your knee recover is to give your knee and ITB a rest. This will allow the natural healing processes of your body some time to take place and will actually speed up the overall recovery process. Usually, this doesn’t mean that you have to be off your feet completely for the whole week more it means that you need to stop any sport and try to do less on your feet for a bit until the initial pain has subsided.
3. Exercise & Strengthening: For the majority of people with ITB Syndrome physiotherapy, exercise and strengthening will be the best approach. The most important factor with exercises is that they need to be progressive and start at a low base in order to allow you to slowly increase their difficulty over time and increase the strength of your ITB.

Okay, I think we have looked at enough possible options here, the main thing that I have wanted to convey is that ITB Syndrome, although difficult to deal with usually responds well to physiotherapy, early assessment and a slow and progressive increase in exercise and strengthening.

How Can ThreeSpires Physiotherapy Help with My ITB Syndrome?

Physiotherapy is extremely helpful if you have ITB Syndrome and one of our physiotherapists who is experienced with managing and treating ITB Syndrome will be able to help. We can help in a  number of ways:

1. Assessment & Diagnosis of ITB Syndrome: this as mentioned earlier is a vital part of managing your ITB injury and the sooner you have an assessment the sooner you will know what you are dealing with. Our physiotherapists will be able to comprehensively assess your knee, make a diagnosis and also identify underlying biomechanical causes of your ITB Syndrome such as core weakness.
2. Management Plan: once a diagnosis of ITB Syndrome has been made it is vital that you get a clear and comprehensive plan to optimise your recovery. Your physiotherapist will be able to identify the best strategy for helping with your ITB and will be able to advise on the best exercises, the optimal recovery and management plan and how to get back to your chosen activity.
3. Exercises for ITB Syndrome: your physiotherapist will be able to determine which are the most appropriate exercises to help strengthen your knee, help the ITB recover and also strengthen surrounding structures and areas of the body.
4. Treatment for ITB Injuries: In conjunction with load management and exercises your physio will be able to use soft tissue and hands on techniques to treat any areas of your legs that have become overloaded and tight.
5. Supplementary Exercises for ITB Syndrome: as part of your assessment for your ITB your physiotherapist will also look at strength and biomechanics in your legs and see if there are any imbalances or weaknesses that might be contributing towards your ITB getting overloaded. As such they will likely prescribe a series of other exercises designed to improve strength and control and help you reduce the likelihood of further injuries.

Okay, I hope that you have found this article about ITB Syndrome helpful. Should you or anyone you know have ITB Syndrome please get in touch and one of our physios would be happy to help.