What is ITBFS?
The ITB is not a muscle but a thick band of connective tissue that stretches from the outside of the pelvis down past the knee joint to the outside of the shin bone (tibia). There are two muscles that insert into the band, the Gluteus Maximus and Tensor Fascia Late. The ITB is important in providing lateral stability to the knee.
So as the name suggests there is a point of friction which can cause pain. As the knee straightens and bends during running the ITB can rub on the outside of the thigh-bone (femur). This may cause repeated friction and lead to inflammation of the band or underlying tissue.
A common misconception is that the ITB is tight and that this is what causes the problems. There are people who do present with tightness but this is often as a result of something more complex. So treating the tightness rarely makes the pain go away.
The ITB passes over the knee joint and can occur with other knee problems such as issues with the cartilage. There is also a nerve that is called the peroneal nerve that passes very close to where the ITB inserts and this can be a source of symptoms in this area. So it is important to get an accurate diagnosis before thinking about what treatment is best.
What causes it?
As with Exercise Induced leg Pain, which I wrote about in my last blog, it is classified as an overuse injury. So the causes of ITBFS can be split into
- Training errors – e.g too much too soon, insufficient recovery
- Altered biomechanics – which relates to how the motion of running is controlled through the joints and muscles of the leg and pelvis.
Due to where the ITB attaches, the pelvis and gluts are very important and a lot of people will present with some gluts dysfunction. The angulation of the knee and the foot position can also make someone prone to getting ITBFS. Asymmetry in one limb compared to the other can be a risk factor as with any over-use injury.
How to treat it?
It is great to have the opportunity to write this blog as I can finally say to a decent amount of people that using a foam roller will not cure ITBFS! There are a lucky few patients with ITBFS who come with good mechanics and no training errors and have just got tight and do respond quickly to soft tissue release/foam roller. But by far the majority of people will present with a more complex mix of training errors and biomechanical problems.
The pain from ITBFS often starts with inflammation and this takes time to build up, so a lot of people only start to feel the pain after a run. The typical patient will report an increase in mileage and may have increased too quickly, not allowing their body to adjust. Once it starts it is VERY difficult to calm down. And the mistake a lot people make is trying to continue running and seeking help too late….and/or believing that a foam roller will cure all evils!
The treatment mostly involves:
- Correcting biomechanical dysfunction.
- Temporary alteration of training that will often require a total break from running – as otherwise it won’t settle.
The movement faults that a patient presents with – e.g reduced gluts activation or reduced stability at the pelvis will form the basis treatment. One of the tests we look at to assess someone’s movement is a single leg squat. So this is something you can try: stand in front of a mirror and look at your pelvis and your knee and watch how they move as you perform a shallow single leg squat. If your pelvis tilts downwards so your “belt line” is not level (this is sometimes difficult to spot) or your knee deviates inwards then you probably don’t have ideal mechanics.
Many people manage just fine outside of these “ideal” mechanics. But there is good evidence that links these altered mechanics to increase stresses and potential for injury in the lower limb. So the important thing is if you have pain and altered biomechanics together then this is something that should be corrected; otherwise leave well alone.
If conservative measures fail, then other types of treatment will be considered such as a steroid injection into the bursa (sack of fluid that sits behind the ITB to prevent friction) if it is inflamed. But physiotherapy is the first line of treatment as an injection will only offer temporary relief at most if the mechanics are not sorted out. As the initial source of pain comes from inflammation it can often be useful to have a short cause of anti-inflammatories. But again this will not solve the problem if the movement patterns stay the same.
So hopefully you can start to see why a foam roller is not a magic wand. In fact there are no magic wands with ITBFS. It is a difficult condition to treat and can often take some time to improve.