Anatomy: The iliotibial band (ITB) or iliotibial tract is a band of connective tissue that runs from the top of the pelvic bone down the side of the hip and thigh and to the side of the knee. The muscles of the hip, buttock and thigh have fibres attaching into the ITB and tightness in these muscles can cause tightness in the ITB.
Injury: It is thought that too much force or tension through the ITB can compress muscle fibres or tendons that lie deep underneath it. This compression causes painless breakdown of the muscle or tendon tissue. If this damaged tissue is overloaded it then causes pain.
The degeneration and pain can occur at a few different spots under the ITB:
1. Under the starting point of the ITB at the iliac crest (side of the pelvis)
2. Under the point where the ITB crosses the greater trochanter (side of hip)
3. Where the ITB crosses the lateral femoral condyle (outside of the knee)
The pain you may feel is often worst at one of these 3 points but can occur anywhere along the ITB.
Pain in zone 2 is more common in women or the elderly. The pain around the hip may occur when walking, be increased with going up stairs, getting into and out of chairs, and also when lying on one side in bed at night.
Pain in zone 3 is common in recreational runners. It may occur initially at the end of a run or running up or down hills. Continued training runs may cause the pain to occur during the first few minutes of activity, ease as you warm up, and come on again at the end of session. As the condition continues to progress the pain may be continuous throughout activity and will stop you running. It may become painful to walk early the next day or after rest particularly up or down slopes.
What causes too much tension in the ITB? And what causes increased compression over the deep areas?
Tension in the ITB is greatly affected by the amount of activity in the muscles that attach into it. These muscles are the Gluteus maximus, Superficial Gluteus medius and Tensor Fascia Latae, and parts of Vastus Lateralis. These muscles can be seen on the chart on the previous page.
These muscles may become overactive and inhibition of the deeper muscles of the hip occurs if we undertake movements that involve too much hip adduction. Hip adduction is where the knee moves in toward the midline or the hip and trunk moves outwards over the knee. Examples of everyday movements that involve hip adduction include: crossing the legs while standing or sitting, resting your weight on one hip while standing, lying on your side with knees together. Adduction of the hip also occurs with walking and running. Sometimes if you have poor hip control, or if you have too much movement through the foot you may get excessive hip adduction while you walk or run.
The increased muscle activity increases tension in the ITB at rest, also. This compresses the deep structures even while you are not in adduction positions and continues to cause the degeneration of the deep structures. Leg length differences, pelvis alignment problems, footwear, and working /training surfaces can also increase the amount of compression on the deep structures.
How do I get better?
Improving this condition is a matter of allowing the deep muscle structures to repair properly. The first step is Decompression. That is reducing the overall amount of compression the structures experience each day. This means avoiding the hip adduction activities already noted above and improving your ability to control it when you are moving around. This list of don’ts and do’s gives you a good guide on things you can do to help improve your condition. The list also gives you some ideas of other changes that may help your recovery.
- Get into compression positions
- Crossing legs in sitting or standing
- Resting on one hip or forward on both hips in standing
- Lying on your side with knees together
- Sitting in deep bucket seats with knees higher than hips
- Rest completely: complete rest from all activity inhibits the function of the deep hip muscles and is rarely beneficial
- Begin a heavy exercise program: weights, resistance, or increasing your training load will just encourage over activity of the incorrect muscles
- See your physiotherapist
- Modify your activity levels so that you have less than 5/10 pain and no increased soreness/ stiffness the day after
- Reduce time spent in compression positions
- Pillow between knees at night and an eggshell underlay may help
- Maintain good posture throughout the day
- Avoid hill running or walking
- Use alternate forms of cardiovascular exercise eg. Swimming with pool buoy between knees
- Ensure you wear shoes with good cushioning for improved shock absorption.
- Avoid training / walking / working on hard surfaces or sloping surfaces.
- Undertake a therapeutic exercise program as prescribed by your physiotherapist to improve the balance between the deep and superficial hip muscles, and to improve muscle activation throughout the pelvis and trunk
- Physiotherapy release of superficial muscles such as tensor fascia latae(TFL), upper glut max and vastus lateralis reduces the resting tension in the ITB
- Reducing your levels of abdominal fat through dietary modification may be beneficial
- Increasing levels of omega 3 fatty acids, reducing saturated fat, increasing fruit, nut, vegetable and whole grain intake, and consumption of green tea has been linked with decreasing signs of the type of degeneration seen in Compression Syndromes of the ITB
How long does it take to get better?
Working hard at following the activities on the don’ts and do’s list and improving your deep muscle control as guided by your physiotherapist should help minimise your discomfort significantly in the short term 1-3months.
The next 3-6 months is about rebuilding tendon strength, and improving the muscle endurance and ability to control higher loads.