Iliotibial band syndrome (ITBS) — also misleadingly known as iliotibial band friction syndrome — is a common1 repetitive strain injury that causes pain mainly on the side of the knee, especially when descending stairs and hills. It is often maddeningly stubborn. The injury mainly plagues runners, but a few unlucky cyclists and hapless hikers will get it too, and it may even be common in inactive people in the aftermath of a knee surgery or other unknown causes of vulnerability.
Pain on the side of the knee is notably different from the other common kind of runner’s knee, patellofemoral pain, which causes pain on the front of the knee and often gets mixed up with ITBS. Another common point of confusion: contrary to popular belief, ITBS is not a hip or thigh problem — that’s something else (more below).
Although IT band syndrome is common, there are no clearly effective treatments for it, just a mess of options ranging from imperfect to completely bogus. Most popular approaches, like stretching, have major problems. Like almost everything in sports and musculoskeletal medicine, ITBS is surprisingly neglected by science and poorly understood, while several simplistic myths about it persist — like the idea that it is a “friction” syndrome, which the evidence clearly points away from.
Here are some examples of wrong and obsolete IT band treatment that patients constantly encounter. (More support for these points later — this is just a debunking sampler.)
- IT band stretching is the king of the conventional wisdom, in spite of good evidence that stretches don’t work, especially the basic ones usually seen in the wild.
- “Elongating” your iliotibial band with intense massage strokes is one of the most popular alternative treatments for ITBS, but it works about as well as it would on a truck tire. Meanwhile, better targets for massage are often neglected.2
- Quadriceps training is a therapy for another kind of knee pain, but — weirdly— it often gets prescribed as treatment for ITBS. This is a simple case of mistaken identity, but you’d be amazed how often it happens.3
- Most doctors are barely aware of IT band syndrome,4 and often neglect (or overemphasize!) the medical options, like cortisone injections or IT band release surgery. Those might help a few people, but they shouldn’t be your first, second, or even third line of defense. Even specialists — sports medicine doctors and orthopedic specialists — often don’t know enough to guide you in these choices. They are usually too preoccupied with other medical priorities to be very knowledgeable about a “minor” condition like ITBS.
This video goes into more detail about some of those points, and introduces several key concepts — all of which can also be found in the text below.
GO TO TOP • CONTENTS • NOTES
The classic ITBS symptoms are just lateral knee pain when exercising, especially walking or running downhill. That’s enough to clinch a diagnosis for many people, but there’s definitely more to know:
ITBS symptoms are most likely to crop up while going down—so trail runners & hikers are at the greatest risk.
- The epicentre of the pain is mainly sharp or hot pain on the outside of the knee. There might be some discomfort nearly anywhere else around the entire knee, particularly in severe cases, but the worst spot must be on the outside of the knee for an ITBS diagnosis (see the next section for even more location detail). That spot will also be sensitive to poking pressure.
- ITBS is an overuse injury and usually starts with a bigger-than-usual workout run, hike, or walk, especially if there’s a lot of descent (stairs, hills, mountains). The classic onset scenario is going down a big hill when you’re already tired.
- ITBS usually starts quite quickly, often without much warning, within minutes or perhaps an hour or two. But it’s never going to be sudden like a sprain.
- For some people, the pain starts after knee surgeries or other knee traumas. For these more vulnerable patients, ITBS can be triggered by much lighter activity than a classic overuse case, but there’s often still an activity trigger.
- Many patients with chronic ITBS feel fine most of the time, but suffer exasperating flare-ups whenever they walk or run for too long. They also usually learn to beware of going down stairs or hills. Hikers with ITBS may be completely fine with virtually any activity except coming down a mountain.
- However, some severe cases do cause continuous pain, or pain with virtually any use of the knee. But even those cases are still obviously aggravated by activity — especially going down stairs.
Later on, I’ll go much further into the topic of diagnosis: whether or not to get an MRI, the role of hip and thigh pain, conditions that get confused with ITBS, some all-too-common misdiagnosis horror stories, and much more.
GO TO TOP • CONTENTS • NOTES
“Runner’s knee” can be either IT band syndrome or patellofemoral pain.
“Runner’s knee” is not one condition. There are two flavours of it (at least). Let’s make sure you’re reading the right tutorial, because ITBS is often confused with the other common runner’s knee injury: patellofemoral pain syndrome. Although the two conditions may 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 (the side facing out), and the epicentre of the symptoms is always there, by definition.5 More specifically:
- the outward-facing side of the knee
- at or just above the prominent bump of bone (lateral epicondyle)
- well-defined pain location, an epicentre you can point to with precision
- fairly superficial — on the side of the knee joint, not in it
Patellofemoral pain syndrome (PFPS): mostly about anterior pain, not lateral
Which condition is “runner’s knee” — ITBS or PFPS? Trick question: they both are. They are constantly mixed up because they are both common repetitive strain injuries of the knee, causing pain in locations that are right beside each other. But while ITBS causes focal pain on the side of the knee, PFPS is all about more diffuse pain on the front of the knee — so much so that it is also often called “anterior knee pain.”
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.
PFPS is a bucket diagnosis that covers several of the possibilities, a condition of many conditions. If you have knee pain with a location that isn’t quite right for an ITBS diagnosis, its may be worth looking at PFPS as a possibility.
Despite the clear side vs. front distinction, confusion about the difference between these conditions abounds. For a more detailed comparison, see Diagnosing Runner’s Knee. Or, if you obviously have pain that dominates the front of your knee, then you should just switch right now to my guide to patellofemoral pain.
Is hip pain a type of IT band syndrome?
No. Pain on any part of the thigh or hip is something else — even if the IT band is involved in some way, it’s still not “IT band syndrome.” Greater trochanteric pain syndrome (GTPS) is the most common kind of unexplained hip and thigh pain. This guide covers hip pain as well as knee pain, because it might be a complication or partial cause of ITBS.
This kind of pain is never “IT band syndrome.” Despite the fact that the IT band does exist there.
GO TO TOP • CONTENTS • NOTES
Lateral knee pain may develop in many people who’ve recently had a total knee replacement. This does not seem to be a widely known fact, and I’ve become aware of it only because so many readers of this page have emailed me to ask: “I am not a runner, but I had surgery and now I seem to have runner’s knee. Is that possible?”
Almost any amount of activity may be like “overuse” if your knee has been disturbed by surgery.
Sure it is. In the aftermath of surgery, people’s knees are so vulnerable that essentially any amount of activity constitutes “overuse.” For a healthy young runner, it takes a bunch of running to do this to their knees. For an older person after knee surgery, normal non-athletic activity will do the same. It is still fundamentally an overuse condition, just with an absurdly low threshold for the amount of activity required to cause trouble.
Once you have ITBS, how it works and how to treat it are probably quite similar. But not identical. This tutorial probably isn’t ideal for post-surgical cases: it may be relevant to many patients, but misleading/irrelevant for others.
Post-surgical lateral knee pain that is not an IT band problem
It’s also possible that some or all of these post-surgical cases are not really true IT band syndrome. In my experience, many of these patients are diagnosed quite carelessly by their surgeon, with a bit of a shrug, just tossing out a diagnosis that’s a rough fit for lateral knee pain. Most of them probably don’t actually know much about ITBS.
Surgery is notoriously prone to puzzling complications and many patients will suffer from chronic pain with no clear mechanism. Maybe the only post-surgical patients being diagnosed with IT band syndrome are the ones whose symptoms happen to have a superficial resemblance to IT band syndrome. But no one knows. As you’ll learn below, even runner’s knee for runners is poorly understood. For post-surgical patients, the nature of lateral knee pain is even more inscrutable.
GO TO TOP • CONTENTS • NOTES
We can put a man on the moon … but we can’t treat IT band syndrome. Here’s some important basic context for anyone setting out to learn more about their case: musculoskeletal medicine is a bit of a backwater.6
No wonder therapy often bombs: it’s just not studied enough,78 and treatment for it is not taught to physical therapists and doctors.9 I have a big sports injuries text that coughs up only a few short sentences, breezily concluding that “the prognosis is good with appropriate treatment” — without even saying what the treatment is!10
“Further Study Is Needed” … for virtually all sports injuries and musculoskeletal pain problems. But ITBS is unusually bad: very common, amazingly unstudied.
Sports medicine in general is amazingly primitive considering how much potential funding it has. You’d think anything affecting elite athletes with huge audiences and deep-pocketed would be getting more attention! The situation is improving, but only recently and it still has a long way to go.11
I have suffered from IT band syndrome myself — see my own IT band story in Appendix A below (grizzly bears included). I have also seen many stubborn cases of it in my own patients (I was a massage therapist for a decade in one of the runningest cities in the world, Vancouver). The prognosis for iliotibial band syndrome is not always good, and many common treatments are ineffective.12 Many people recover with a little rest, icing, and stretching, but not everyone. And probably not you, or you wouldn’t be reading this.
Let’s get into it …
GO TO TOP • CONTENTS • NOTES
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 — once seen as basically mechanical, like brake pads wearing out— have proven to be scientifically messy and bizarre. Chronic pain of any kind turns out to be a neurological rabbit hole. Much that was once considered “obvious” or “common sense” has been proven embarrassingly wrong. Researchers have only just begun to try to find out what’s really going on. Maybe.
On the face of it, iliotibial band syndrome is still a simple condition, caused by excessive knee usage and mostly treated by resting. But to anyone who can’t get rid of it just by resting, it is equally obvious that there must be more to it than that …
Iliotibial band syndrome is mainly a running injury, responsible for about one in twenty lower limb injuries in long-distance runners.13 Probably at least a quarter of all long-distance runners will be stricken eventually. It is as common as dirt, and roughly one in twenty-five people who do any kind of vigorous physical training will get a case of it.1415 So basically it’s mainly (though not exclusively) an overuse injury.
Homo sapiens may be good at running, but that doesn’t mean it’s easy or risk-free.
Throughout hominid history, if you’re running 26 miles in a day, you’re either very intent on eating someone or someone’s very intent on eating you.
Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 123
Just to put this in perspective, iliotibial band syndrome is probably not much less common than ankle sprains, which are generally regarded as the most common of all athletic injuries.16
Iliotibial band syndrome is also prominent in cyclists17 — even though each stroke of the pedals is probably much less irritating to this knee condition than running, sheer repetition can certainly make up for it. Hiking, backpacking, orienteering, and frequent long walks can also cause the syndrome.18 Maybe in the future it will be known as Pokémon trainer’s knee.19
The conventional wisdom says that iliotibial band syndrome (ITBS) is a kind of tendinitis. 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 — the alleged rubbing — it is also commonly called iliotibial band friction syndrome (ITBFS).
Makes sense. Right? Well, not anymore. Iliotibial band friction syndrome is probably not a “friction” syndrome after all — and 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 obsessed with trying to loosen tight IT bands!
GO TO TOP • CONTENTS • NOTES
In 2007, John Fairclough of University of Wales Institute, with seven coauthors, issued a major challenge to the classic 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.2021 They make a strong case, concluding that “the perception of movement of the ITB across the epicondyle is an illusion.” They’re saying the function, dysfunction and actual anatomy of the IT band has been misunderstood all along.
It’s a charming example of how primitive medical science still is. Can we really still be learning anatomy this late in history? Oh, hell yes!22 Of course.
(Not only still learning, but still arguing about it. A few years later, Jelsing et al. came along and used ultrasound to show that the IT band does move back and forth — even though they agree that the IT band really is firmly anchored to the side of the knee. There is no good solution to this paradox for now, but for a few reasons I still think it’s best to think of friction as an obsolete idea. Much more about Jesling’s fly-in-the-ointment evidence below.)
The author’s knee. The forward edge of my IT band is prominent at the level of the knee, but doesn’t even particularly appear to move across the epicondyle, let alone actually do it. It just pops out. Fairclough et al.: “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.23 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 this is what makes IT band syndrome such an interesting subject. Now, here’s what did happen …
Several of these young women athletes did get iliotibial band syndrome that season. It was the most common injury in the group.24 But these expert assessors determined that not one of them had tight iliotibial bands. Not even one!
All the athletes with iliotibial band friction syndrome had a negative bilateral Ober test [their IT bands were not tight].
It was just a few athletes, and the Ober test isn’t a good test,25 but it doesn’t detract from the main message: it’s not safe to assume that a tight ITB matters.
The conventional wisdom was such a nice, straightforward picture of the condition that no one was apparently motivated to question it — after all, ITBS is a relatively minor problem. Most cases resolve spontaneously or with conservative treatment, and the others respond pretty well to a simple surgery. Why rock the boat by challenging the very definition of the problem?
Because that simple picture is almost certainly wrong! “Minor” or not, many consumer dollars have been wasted on therapies based on that wrong picture. What little research there is has been undertaken under the influence of bogus basic assumptions about how ITBS works. If we understand the condition as it truly is, maybe someday it can be treated more efficiently and conservatively, without surgery (or more effective surgeries).
So, what exactly is iliotibial band syndrome? To answer that, we need to talk anatomy. Hang on, you’re about to learn some Latin. You will be able to amaze your running buddies with your knowledge. Your authoritative command of ITB anatomy will blow them away!
GO TO TOP • CONTENTS • NOTES
The iliotibial band is usually described as a tendon — a big one. (Quick refresher: tendons connect muscles to bones, while ligaments connect bones to bones.) The IT band is so big that it’s also called the iliotibial tract : no other tendon is known as a “tract”! It is often called the largest tendon in the body, which is sort of true, but it’s clearly not just any tendon. It’s a rather special and complicated one …
- This tendon is also technically a ligament: that is, a connective tissue structure that connects bone-to-bone, rather than muscle-to-bone. The ITB is attached to the pelvis as well as the knee. It’s the only major example of a ligament-tendon hybrid in the human body.
- Most tendons are dwarfed by the muscle they belong to, but the iliotibial band is much more massive than it’s tiny tensor fasciae latae muscle (TFL) — several times longer and much wider.
- Although the gluteus maximus also partially uses the iliotibial band as a tendon, the connection is at an odd angle: the job of the gluteus maximus is probably not to pull directly on the iliotibial band (like most muscle-tendon relationships), but to increase the tension on it by pulling on it laterally (like drawing a bowstring).
- The IT band blends seamlessly into the capsule around the knee (which is why your knee seems to “cinch up” during a good iliotibial band stretch26).
- Most tendons have clear edges and are well separated from other tissues. The IT band is more of a reinforced section of the connective tissue container for the whole thigh — like a tough part of a sausage wrapping.27
- It’s an energy storage device, a leg battery. It stores some elastic energy during part of our stride, and then releases it to give us a little boost, just like the Achilles tendon. It’s a minor effect, much less than the Achilles tendon, but it’s one of the things that makes it an eccentric bit of anatomy.28
- In addition to blending with the connective tissue wrappings of the thigh and the knee joint capsule, the IT band is quite well-connected with many discrete deep attachment points (“insertions”) on the femur, the tibia, and the patella.29 A couple of these have been discovered surprisingly recently, and one of them is especially relevant to runner’s knee …
- Most importantly, the IT band is tightly anchored to the full length of the femur, from hip to knee — especially just above the knee.
- Oddly, the upper reaches of the IT band also penetrate all the way into the hip, from the bottom of the tensor fascia latae (TFL) muscle to the lateral surface of the hip joint, which it entirely covers.30 This feature of the IT band was first clarified in 2017. The feature has no direct relevance to IT band syndrome, but it’s interesting anatomy that’s really at odds with the conventional picture of the IT band as a superficial strap running down the outside of the thigh.
Superficial dissection of the knee, highlighting the iliotibial band. Notice how it widens & spreads out as it nears the knee.
It’s the last three points that are really important to understand—all that anchoring to deep structures. Most people still think of the IT band as being free to move relative to the femur, like any other self-respecting tendon: a strap that lies under the skin, separated from the femur by a thick layer of quadriceps muscle. But the iliotibial band is not free to move relative to the femur, or so little that it doesn’t count. It is anchored to the femur between the big muscles of the front and back; it clings to it like a barnacle to a rock,31 even right where it slides back and forth over the side of the knee.
This is why Fairclough et al suggested that “the ITB cannot actually create frictional forces by moving forwards and backwards over the epicondyle during flexion and extension of the knee.” The anatomy only creates the illusion of a slide over the side of the knee.3233
That mental image of the IT band snapping over the side of the knee is prevalent and misleading, the reason for some futile treatment strategies. This is an advanced and obscure anatomy puzzle; many pros will never learn more than they did in school, which was probably still wrong even if they graduated this year, even 15 years after Fairclough et al’s paper. The state of anatomical knowledge in general is a cringe-inducingly poor.34
But the truth is out there! The ITB is a unique connective tissue structure with some properties of a tendon, others of a ligament, and an unusual tension control system consisting of a couple of hip muscles at the upper end, and it probably does not slide significantly over the side of the knee.
Cartoon by Loren Fishman, HumoresqueCartoons.com
GO TO TOP • CONTENTS • NOTES
Fairclough et al argued that the iliotibial band itself is not the irritated structure in ITBS. If not, what is? Something under the IT band is the simplest answer at this time:
- either a normal bursa (padding) that has become irritated
- a bursa that has grown in reaction to stress, like a callus
- and/or a deeper, bursa-like pocket of tissue around the fibrous attachments of the IT band to the knee
It isn’t possible to say for sure which of these is true, and there is likely to be some truth in all of them. What is more certain is that it’s not the IT band itself that hurts but miscellaneous stuff between it and the side of the knee. This alone, regardless of the details, has significant implications for the definition of iliotibial band syndrome and its treatment (especially if that treatment is surgery).
Although the details may still be sketchy, the basic point is now on pretty solid scientific ground. It makes some mechanical sense based on new understanding of the anatomy, it is supported by MRI studies showing an abnormal appearance in the scan compared to healthy knees,3536 and a dissection study has also shown evidence of it.37
Most importantly, a few surgeons are now successfully treating iliotibial band syndrome by removing tissue from under the IT band, leaving the IT band itself untouched, or barely touched. This is a remarkable result — a game changer, in fact. It was first reported in Belgium early in 2009, and was followed later that year by an American team describing a similar procedure. This surgery will be discussed more thoroughly below — this is only the beginning of its implications.
It’s easy to fall into the trap of thinking that this is a trivial difference: who really cares if it’s the IT band or something immediately under it? But it’s not trivial: it’s the difference between the rock in your shoe and the shoe itself.
Do you want to loosen the shoe? Or get rid of the rock?
GO TO TOP • CONTENTS • NOTES
Historically, ITBS surgeries have all focused on either removing the section of the IT band that is compressed against the side of the knee, or on loosening the IT band so that it doesn’t press on it as hard. That approach has worked to some degree, but the success rate is not as good as anyone would like, and recovery takes a while because the structural integrity of the IT band is compromised.
The evidence presented above suggests that the irritated tissue is probably not the IT band itself, but the tissue under it. Wouldn’t it be great if this idea were so well-developed that it inspired a new surgical approach to the problem? A surgical approach that worked better? A surgical approach that cured iliotibial band syndrome simply by removing that irritated tissue?
In fact, that’s exactly what happened in 2009.
From 2003 to 2007, inspired by the findings of Nemeth and Fairclough and others, a group of Belgian surgeons operated on 35 knees, trying to solve IT band syndrome in a new way, based on an upgraded understanding of the anatomy.38 Instead of the old surgical approach, they used “resection of the lateral synovial recess.” That is, they removed tissue from a fold or pocket surrounding the (previously unknown) fibres anchoring the IT band to the femur. They went into that space arthroscopically — inserting tiny instruments through a tube no bigger than a straw — which has some great surgical perks (see sidebar).
“If the inflammation39 is limited to the fibrous attachments to the femur and the surrounding fat,” they wrote, “there’s no need to resect a part of the ITB [cut it to loosen it].”
That’s it. No loosening of the IT band. And yet it seemed to work. Thirty-four knees had good or excellent results. All patients went back to sports after 3 months. The authors of the study concluded, “that arthroscopic treatment of resistant ITBS is a valid option with a consistently good outcome.” If the pain of ITBS were not coming from that fatty layer, the surgery would not have worked at all — perhaps not even one patient. “The good results of this treatment confirm the hypothesis that the inflammation is limited to the fibrous attachments to the femur and the surrounding fat. No resection of the ITB is needed.”
Replication is nice
One study alone can’t prove anything, so it’s comforting to know that another group of American surgeons tried a similar approach and also got excellent results — with some educational differences I’ll cover in the next section.
This all has to be tested more thoroughly, and it probably will be. But these are unusually promising results, and surgeons around the world are now trying it with their patients. The old methods were effectively experimental as well — this is just an experiment based on better information. Surgery is an amazingly pragmatic discipline, in which procedures are routinely (cautiously) chosen on the basis of no better than an educated guess. The old method was one guess, and it wasn’t a bad one — but it seems likely that this new method is a better guess.
The results are clinically important, but also just fascinating: a wonderful demonstration of the power of knowledge to suggest a new solution to a difficult puzzle. It’s amazing what you can do when you understand something just a little bit better. This is “reductionism” at work — the same “reductionism” that so many alternative health care professionals turn their noses up at. This is finding and treating more than just the symptoms. And it was achieved through difficult, expert scientific investigation! For years I have been reporting on the evidence about ITBS — and these doctors are actually acting on it, trying something new, and it’s working.
Meanwhile, there are literally millions of patients with ITBS, and probably 98% of them (and their doctors and therapists) still think the IT band itself is irritated and too tight. These recent surgical studies have shown that it’s not quite like that. And that is why professionals must read scientific journals (and tutorials like this one).
GO TO TOP • CONTENTS • NOTES
It’s time to head into the here-be-dragons section of the map of IT band syndrome.
This tutorial has still not answered the question: what exactly is irritated? I haven’t answered it because I don’t know, because no one knows. The Belgian and American surgeons who have published about this removed different irritated tissues from under the IT band, but both got good results.
Because Michels et al got good results by removing fatty tissue from the lateral synovial recess, their work appears to constitute strong evidence that ITBS is probably not so much a “tendinitis” as it is a “fatty-tissue-itis.”40 The most precise description of this is an “enthesopathy” — a disorder of tissue attaching directly to bone.
Michels et al: “Because ITB overuse injuries may be more likely associated with fat compression beneath the tract, they [Fairclough et al] consider it as a form of enthesopathy.”
But the Americans took a different approach. They treated the problem like a bursitis.41 And why not? The evidence shows that there’s something under the IT band that’s the problem, and that’s the nature of bursae — they are underneath and between things. A bursa (plural bursae or bursas) is a peculiar bit of anatomy: a small sack of slimy (synovial) fluid, like raw egg white, which reduces friction between structures, like between skin and bone or between a bone and a tendon. The name comes from the Latin for purse.
“Iliotibial bursitis” has always been one of the many ways of naming iliotibial band syndrome (although out of fashion lately; it sounds as quaint as “lumbago”). Most professionals assume that there is a bursa between the IT band and the side of the knee, and most of those probably assume that the bursa is in trouble. So Hariri et al operated with the assumption that it was a bursa that was the problem. They looked for bursae, they found bursae, and they removed bursae…
And they got good results. How puzzling! Because there aren’t actually supposed to be any bursae under the IT band.
Bursae do occasionally become painful, but it’s an overdiagnosed and usually minor condition that quickly resolves on its own. Family docs are notorious for chalking up many minor body pains they can’t explain to a bursitis, and this certainly occurs in the case of ITBS. It also works the other way around: there are two somewhat common bursitises in the area — prepatellar on the kneecap,42 and trochanteric on the side of the hip43 — that also get incorrectly diagnosed as ITBS, even though they aren’t in the right places at all.
Another bizarre scenario is that a kind of bursa may form, like a kind of internal callus, in response to stresses! These are pathological “bursa-ish” structures whose form follows the same function as bursa, and thus they are called bursa, while actually being quite different.
But the lack of a bursa under the IT band at the knee was reported by three groups of researchers we’ve already mentioned — the very same researchers who inspired new surgical approaches to the problem — plus another.
- In 1996, Nemeth showed that “the tissue under the ITB consists of a synovium that is a lateral extension and invagination of the actual knee joint capsule and is not a separate bursa as described in the literature.” They’re saying it’s bursa-like, but specifically saying it is not actually a bursa.
- In 2007, Fairclough et al reported that “a bursa is rarely present, but may be mistaken for the lateral recess of the knee.” They called the structure a “lateral synovial recess.”
- Then in 2009, Michels et al actually targeted tissues in the lateral synovial recess with literally surgical precision. They didn’t find bursae either.
- And Falvey et al “failed to demonstrate a bursae between the LFC and the ITB on a single cadaver.”
Yet Hariri et al operated on what they called “bursae,” provided nice pictures of the bursae that they removed from people’s knees, and those people were subsequently happier people.
What on Earth is going on here? Clearly not all of this can be quite right.
Maybe it’s splitting hairs. That lateral synovial recess may function much like a bursa, perhaps so much so that it’s a trivial distinction: bursa, fold, recess, pocket, callus-like-growth-of-bursa-esque tissue … whatever. If the problem is that the contents of this recess get irritated, that would be so functionally similar to a bursitis that it seems silly to quibble over the name.
But I’m not convinced by that: a bursa is not a lateral synovial recess, and enthesopathy is not the same thing as bursitis. I think precision is called for. Inconsistencies like this are exactly what should inspire scientific curiosity.
Maybe the only explanation for all of this is “all of the above.” Maybe some people have real epicondylar bursae and some do not. Maybe some have pathological bursae and some do not. And maybe some people have some irritation in their lateral synovial recess, and some do not. And probably some people have a combination of these things. And perhaps that is why the surgeries — despite generally good results — were not perfectly curative.
GO TO TOP • CONTENTS • NOTES
“Tight” IT bands have a really bad reputation. Regardless of exactly what tissue is irritated, the most likely immediate cause of ITBS is the intensity of the contact that tissue is making with other tissues — in other words, the “tightness” of the iliotibial band. Perhaps the strongest evidence for this is the well-established fact that surgery can reliably reduce the pain by physically loosening the iliotibial band over the lateral epicondyle.
If a looser iliotibial band often solves the problem, then perhaps it’s a too-tight iliotibial band that causes it?
Not so fast. Just because loosening helps doesn’t actually mean that tightness, per se, is to blame. If you are wearing a ring and you injure your finger and your finger swells up, does that mean your ring is “too tight”? Is the ring the thing? No — but it would feel great if the ring got bigger! If you have a rock in your shoe that is uncomfortable, does that mean your shoes are “too tight”? Is the shoe the problem? No — but it would still be a huge relief to take your shoe off and get rid of that rock!
Once irritated, the pad of fat under the iliotibial band may simply be hard to calm down, regardless of whether the tightness of the iliotibial band is “normal” or “too tight” or even “kind of loose.”
What does the science say about IT band tightness? If it’s such a villain, you’d think it would have been studied. But researchers have not “gone there” much. You see authors casually claiming that it’s been studied, but the references are always to general texts, which in turn will make the claim based on indirect evidence and good old “common sense.” It’s just not good enough for me if some textbook author says ITB tightness is connected to ITB syndrome, without actually citing real research. Also, many clinicians claim to detect changes in IT band texture that correlate to symptoms, but I question that too.44
Maybe the answer is Ober here…
There’s a classic clinical test for IT band tightness, the Ober test, that is specifically intended to reveal ITB tightness. That’s what I was taught in school; that’s what it said in my orthopedics text, and every widely used source I’ve seen ever since. Basically the Obert test involves lying on the side, extending the hip, and then dropping the leg… as far is the IT band will allow it to drop.
If the leg can’t drop much, supposedly that means the movement is limited by … the IT band, right? Wrong — yet another failed assumption of musculoskeletal medicine. A straightforward 2016 test of the Ober test in American Journal of Sports Medicine found that the ITB band doesn’t restrict that particular hip movement at all — instead, it’s the hip joint and its muscles.45
And that’s that. So, after a run lasting decades, it’s all over for the Ober test: it doesn’t actually detect the ITB tightness that may or may not having anything to do with IT band syndrome anyway. We obviously oberestimated the value of the Ober test. I am ober the moon to have this cleared up. We wouldn’t want to oberanalyze it now. Are all these puns oberkill? No doubt, but you’ll get ober it.
The closest thing we have to evidence of a tightness-ITBS link we have comes from that one small study by Devan et al, discussed above … which failed to find it. But how did they do the study? “Iliotibial band flexibility was assessed via the Ober test”! *groan*
This changes everything
Does anything detect IT band tightness? Certainly nothing widely known! The Ober test still rules this roost, and I would wager that only a tiny fraction of professionals have even heard the results of Willett et al.… or accepted the implications.
Is there even any significant variation in tightness to detect, regardless of its clinical significance? And how would we know one way or the other if there’s no way to test it?
Willet et al. has even more dire implications: if a supposedly ideal stretch of the IT band, biomechanically optimized, is actually limited by the collective restrictions of the hip joint itself and all its other muscles and not the IT band, then that same stretch used for treatment is in trouble. If you can’t test the tightness of the IT band that way, then you can’t stretch it either. This means that even the best IT band stretches aren’t affecting the IT band specifically — they are just challenges to hip flexibility. This will be an important point in a much more detailed discussion of stretching later on.
Clinicians and runners are so used to thinking in terms of IT band tightness that its potential absence as a factor isn’t even part of the discussion. Despite the implications of Willett et al., I still err on the side of assuming that IT band tightness is something we can at least feel and might want to try to do something about. But everything that depends on the idea of tightness — and that’s almost all the conventional wisdom on this topic — is clearly on thin ice.
The PFPS connection
The reputation of IT band tightness is so huge that it also gets blamed for patellofemoral pain syndrome (PFPS, anterior pain), and there’s one small study of that possible connection — but while it did supposedly find that connection, it’s a weak piece of data.46
There’s no solid ground here, and we truly just do not know if people with iliotibial band syndrome actually have excessively tight iliotibial bands … or just normal iliotibial bands in a bad situation.47 You can see how this lack of certainty causes a serious problem for people who are preoccupied with the “tightness” of their iliotibial band. What if it’s not really too tight in general, just too tight for the situation?
The tightness could be what we could call a “functional tightness” — not so cinched up too tightly in general, but tightening at the wrong time. There are many injuries in the body that involve dysfunctional joint control systems, where poor coordination — zigging when you should zag — either leads to a traumatic dislocation or a chronic irritation. It may be that the iliotibial band is at a perfectly normal length on average, but is tightening up excessively at just the wrong moments.
Or maybe it’s none of the above. Maybe the iliotibial band is tighter in some positions, and we just get into trouble when we spend too much time in those positions. With or without a too-tight ITB, this probably has some truth to it, and that’s what the next chapter is about.
GO TO TOP • CONTENTS • NOTES
Most people who have iliotibial band syndrome describe a rapid onset of symptoms. It doesn’t hit all at once, like a trauma. But it is still quite quick. You notice a little pain, and then sometimes within just a few minutes your knee feels like it has burst into flames.
Rule of thumb: the people who get iliotibial band syndrome are the people who use their knees the most, the runners and cyclists. And it may be that we need look no further for the immediate cause of the pain: repetition. Enough knee movement is probably capable of pissing off nearly any knee, regardless of any other risk factor. That is probably the main explanation for how the pain gets started, but the story takes a funny turn after the pain starts.
Most runners respond to the pain in exactly the same way: they slow down. And that may be a problem. In fact, slowing down may explain why the pain speeds up.
Experts have speculated that a slower stride rate may result in spending more time with the knee at a problematic angle: around 30˚ of flexion, which just happens to be the slice of the arc of knee movement at which the iliotibial band is clamped down most tightly on the lateral epicondyle. The most widely cited example of such speculation is a paper from 1996 in American Journal of Sports Medicine by Orchard et al, who proposed that “sprinting and faster running on level ground are less likely to cause or aggravate iliotibial band friction syndrome because, at footstrike, the knee is flexed beyond the angles at which friction occurs.”48
Slowing down because of the pain could actually cause the pain to get worse much more quickly, resulting in an impressively ironic vicious cycle. If this is the case, it’s not a “tight” iliotibial band that’s the problem, per se, but just that the victim is unwittingly flexing and extending the knee primarily in the range where the ITB is naturally — not pathologically — most firmly pressed against the side of the knee.
Unfortunately, we don’t have much in the way of hard science on this topic — no study of running pace as a risk factor for ITBS has yet been done. So instead of science, I’ll supply a good anecdote. It’s not intended to prove anything, but it is intriguing …
George Ingham of Herndon, Virginia, certainly noticed the effect of running speed on his knee. George is a distance runner who picked up his first case of iliotibial band syndrome running a marathon in March, 2007. The onset was classic: “I took a week off after the marathon to allow my body to recover, and began running again. About two weeks later, I noticed some IT-band-type pain in my left knee. I immediately took two weeks off to rest, stationary biking to maintain aerobic fitness.” That was a good initial response, but it wasn’t enough. When he tried to run again, things went pretty badly …
“For the first week, I felt little-to-no-pain, but after a long, slow run with my girlfriend, my knee felt like it was exploding, and I had to have her run home to get a car to pick me up.”
A long, slow run? That may well have been exactly the wrong thing! George then went through the usual troubleshooting contortions, before ending up at this tutorial several weeks later. Contrast bathing, icing and eliminating his stationary bike training were all important factors, he thinks, but changing his recovery running speed was the most critical:
Beginning a walk/jog program so that I could run fast on my run intervals — so I would not irritate the ITB as much as running slow — loosened up my leg a lot. Had I not read your article, I probably would have gone out and jogged slowly to recover, and that would have just irritated things even more. Instead, running 30 minutes total at a faster pace on the running intervals, but breaking it up with some walking, helped a lot. In fact, if I had to pick one thing that helped most, it would probably be running fast instead of slow.
In fact, rehabilitating with faster, shorter runs helped George Ingham’s knee so much that he ran and won a 5K race just five months after his trouble started, and soon after took 2nd place in a 7K — an excellent recovery from a case of ITBS like he had!
How about a more extreme example? Extreme examples are educational
We know from the experience of ultra runners that it is possible to run in a way that is less hard on your body in general. Exhibit A: Philippe Fuchs, who ran from Paris to Beijing, covering ~5,100 miles in 161 days.49 (I know, wow!)
Fuchs’ primary concern was his “ability to keep absorbing muscular and skeletal punishment day after week after month” of course. By the time he finished, he had developed an endurance stride that was quicker and less air time. That is, he padded along with about 6% more steps per mile (a higher stride rate), a whopping 30% less time in the air, and 11% less landing force. I’m betting he wouldn’t have made it without those adjustments. Fascinating.
His case is hardly direct evidence that a higher stride rate will be better for IT band syndrome specifically, but it is consistent with that theory. More generally, it also just suggests that tinkering with your running style is probably worthwhile.
A final word about hiking. Hikers also get the vicious cycle, rapid onset of symptoms, and at the worst possible time: the problem tends to strike while descending a mountain. The knee has already been used quite a lot to get up the mountain, of course. And then, on descent, there’s less knee flexion … and no escape from the extensive repetition of knee movement right in the danger zone between 25˚ and 35˚ of flexion. Yikes! No wonder it can come on so hard and fast.
GO TO TOP • CONTENTS • NOTES
We can’t even be sure of the proximate cause — the most immediate cause, the one-degree-of-separation cause — of iliotibial band syndrome. There is literally no direct evidence of even the proximate cause of this condition. So hoping for clear “root” or ultimate causes is pretty much a pipe dream.
That doesn’t stop therapists and doctors from trying and guessing, though! Many health care professionals believe that iliotibial band syndrome must be the tip of an iceberg of gait or postural dysfunction, and quite a few specific proposals have been made.
Another for instance: one of my primary and best sources for this tutorial, Dr. John Fairclough, buys in to the hip-strength theory … which I mentioned dismissively in the introduction. Specifically, he writes that “ITB syndrome is related to impaired function of the hip musculature and … its resolution can only be properly achieved when the biomechanics of hip muscle function are properly addressed.” Sadly, he does not say exactly what “biomechanics” or how they can be “properly addressed.” (Actually, he does make suggestions: he just doesn’t defend them to my satisfaction.)
You’ll find similar opinions in virtually any article by physiotherapists or chiropractors. They tend to give the impression that treating “just” the symptoms is terribly inadequate, while making much of the idea that iliotibial band syndrome will just keep coming back if you don’t pull it out by the roots and address the “real” cause … whatever they think it might be. But, like religions, they can’t all be right, and there are many possible ways of explaining just exactly how this syndrome happens, and the evidence to support all of them quite indirect, inadequate, or simply nonexistent, as in case of the bogeyman factor of pronation.50 I don’t doubt that being crooked in some way could be a main factor in some cases of iliotibial band syndrome, because it is generally clear that the human organism tends to break down outside a Goldilocks “just right” zone, especially wherever physical stresses are relentless. There is relatively good evidence that the root causes of plantar fasciitis are related to gait dysfunction and biomechanical disorders of the lower limb, for example. If it happens there, it’s plausible that it happens in the knee as well.
We also have some scraps of evidence that screening tests like the Functional Movement Screen can tell which athletes are danger of a lower limb injury.51 If you cannot do certain physical tasks well, says the logic of the test, then you’re at greater risk for injury. It’s weak evidence, and there are some serious reasons to doubt the validity of the FMS,52 but it’s something and I can’t in good conscience ignore it (even though I think it’s likely wrong).
Maybe the lack of evidence on root causes is (still) due to a lack of research, and not because there aren’t root causes.
And yet sometimes in health care, what is “true” matters less than what is practical, and I question the practical value of treating iliotibial band syndrome as a symptom of mostly hypothetical “biomechanical” problems. There are two serious challenges with trying to fix perceived gait or postural dysfunctions or muscle imbalances, the reason that I have never emphasized these factors as a therapist or a writer:
- Trying to diagnose such root causes is just plain difficult, more art than science. Five experts are likely to give you five different opinions about your gait and posture. One will tell you that your pelvis is out of alignment, another that you have “Trendelenberg sign,” a third that you’re an ankle pronator. The fourth will see a clear tibial torsion, and the fifth might say “all of the above.”
- Even if you have a reasonably clear gait or postural dysfunction, fixing it is probably going to be a difficult, finicky, time-consuming and uncertain business … and many causes of gait dysfunction, such as normal variations or minor deformities in your skeleton, cannot be treated at all, or only compensated for awkwardly.
I’m not saying that gait dysfunctions don’t exist in runners with iliotibial band syndrome, just that it’s hard (impossible?) to pin them down — and even when you can, it’s probably also difficult or impossible to do anything about it. These are a summary of standard problems with structuralism: an excessive preoccupation with underlying biomechanical factors in therapy.53
Also, something both patients and professionals should appreciate: meaningful and skilled gait assessment just cannot be done without slow motion video. Few therapists (arguably none) are such prodigies that they can actually get anything useful out of just watching you run.54 And diagnosis of a gait dysfunction often leads to a wild goose chase: months of therapy, advice, and lots of fiddly little therapeutic exercises that you’re never sure are actually doing anything.
I never got into gait analysis with my clients, and I don’t recommend it to my readers now. Nevertheless, despite the uncertainties, it’s probably worth giving some attention to refining your gait — or even just shaking things up a bit, almost randomly — when you’re trying to troubleshoot a tough case. This tutorial isn’t for “most patients” — it’s for those of you with the most stubborn cases of iliotibial band syndrome, who really want to get back to running (or cycling, or whatever tosses your confetti), and you may be willing to pursue even a thin theory — which is really all there is when it comes to the causes of ITBS.
Still to come in the tutorial are detailed explorations of popular ideas like the relevance of hip strength and barefoot or minimalist running. You can try to strengthen your hips, or run with naked feet, without having a specific theory about what’s wrong with your gait in the first place, and it might just make a difference, directly or indirectly. Strengthening your hips, for instance, could improve the problem not because your weak hips were the “root” cause to begin with, but because the process of strength training leads to running differently than usual, and “change is like a holiday” — for your knees, in this case. Or maybe it’s because hip weakness really was the cause in the first place, despite the problems with that theory. A main point of this tutorial will be to review the sense and science of such ideas, so that you can decide for yourself what’s worth a shot and what’s not.
Just bear in mind along the way that the root cause of iliotibial band syndrome is not running “wrong,” but simply running too much.
GO TO TOP • CONTENTS • NOTES
In 2012 and 2013, it seems to have become strangely fashionable to deny the health benefits of running, and to assert that it actually makes you fatter and erodes muscle and bone! For example, these claims are actually made in John Kiefer’s popular article, Why Women Should Not Run.
All this may come as a surprise to you, since you’ve probably noticed that most runners seem pretty fit compared to the average Walmart shopper. Running can be hard on bodies — you wouldn’t be reading this if it wasn’t — and it’s certainly not necessary to do high-volume cardio to be a healthy person. (And it almost certainly is possible to be fit with less exercise than most people think. See: Strength Training Frequency.)
But it takes mental gymnastics and abuse of the evidence to believe that “cardio above a walk or below a sprint is bad for you (especially if you are a woman).”55 It’s preposterous, and strongly contradicted by the evidence, which — just one key example here — actually shows that runners get less osteoarthritis,56 probably because using joints is a healthy thing to do with them
So much for a simplistic notion of running being hard on the body.
Although this is a new twist, an anti-running or fatalistic reaction to running injuries is hardly new. Many runners with stubborn knee pain have been told (almost invariably by non-runners, I think): “maybe you’re just not built for running.” When your doctor or physical therapist says that, the translation is usually just, “I don’t know what’s wrong with you and/or what to do about it.” This is unquestionably more humble and honest than the professional who overconfidently diagnoses the wrong cause and pretends to be able to fix it (with expensive therapy, probably). However, chalking your knee up to a lemon is also excessively defeatist — even though it could turn out to be correct in a few cases. Despite the admirable humility, the puzzled professional probably still believes that there is a biomechanical root cause, something that inexorably predisposes you to iliotibial band syndrome (or shin splints, or patellofemoral pain, or plantar fasciitis) … and the solution is to tell you to quit running. Or long walks. Permanently. To give up your favourite addiction, or a key component of your lifestyle.
Fortunately, there’s another way to look at the problem.
In the last section, we established in general that the importance of anatomical abnormality is probably greatly overestimated as a factor in knee pain. If not that, then what? The alternative view — and this is the beating heart of this tutorial — is that running is a knee-stressing activity by nature, regardless of whether you are anatomically average or biomechanically quirky, with or without structural curve balls. The fat pad pinched under the IT band — or whatever it is that gets irritated, exactly — is really difficult to calm down once it’s irritated. I am not denying that there are exceptions to this, that some cases might be more mechanical in nature, just asserting that they are probably exceptions to the non-biomechanical rule.
Many people can fairly easily learn to compensate for the natural tendency of the knee to get irritated by a lot of running, but only by diligently focusing on doing everything possible to give that irritated tissue a break. It’s not easy to do, so you really can’t afford any distractions from the goal, especially misguided therapies that actually increase irritation.57 ITBS can often be compensated for if you understand that sometimes your knee will cross that threshold and get pissy again, if you understand that each time that happens you’ll need to apply a specific resting strategy to get it back to the way you want it. This is tricky, but it is do-able!
Let me put it this way: summing your situation up by saying you’re not built for running is like telling an insomniac that they are “just not built for sleeping.” Insomnia is a treatable condition in virtually every case where it isn’t being caused by a disease, and every medical sleep specialist knows this.58 Most insomniacs actually are built to sleep, and no doctor would ever suggest otherwise.
And almost every human is “built” for running. In fact, we’re one of the running-est species on Earth — not the fastest by a long shot, of course, but one of the best long-distance running species, maybe the very best. In fact, it is the most distinctive feature of human athleticism, our claim to fame. For instance, as Dr. Daniel Lieberman explains, “Humans can actually compete with and often beat horses at endurance races.” Especially when it’s hot. Which is cool. Here’s the context of that quote, on not giving homo sapiens enough athletic credit, from the (fascinating) article Brains Plus Brawn (worth a reading detour, and Dr. Leiberman will come up again later in the book when it’s time to talk about natural running):
We’re actually remarkable endurance athletes, and that endurance athleticism is deeply woven into our bodies, literally from our heads to our toes. … We’ve lost sight at just how good we are at endurance athleticism, and that’s led to a perverse idea that humans really aren’t very good athletes. A good example is that every year they have races where they actually compare humans and horses. In Wales, this started a few years ago, I guess it started out as a typical sort of drunken pub bet, where some guy bet that a human couldn’t beat a horse in a marathon. They’ve been running a marathon in Wales for the last, I think 15-20 years. To be fair, most years, the horses beat the humans, but the humans often come very close. Whenever it’s hot, the humans actually beat the horses.
The point is not that humans are poor athletes, because the horses occasionally beat us, but humans can actually compete with and often beat horses at endurance races. Most people are surprised at that. … One of the interesting things about these races also is that they’re so worried about the horses getting injured, that the horses have mandatory veterinary check-ups every 20 kilometres, but not the humans, because humans can easily run 40 kilometres without injury. But if you make a horse gallop for more than 20 kilometres, you seriously risk doing long-term permanent musculoskeletal damage to the horse.
We obviously aren’t “built” to run on concrete exclusively, and we’re certainly not “built” to continue running on an irritated knee — nature has limits — but a wide range of body types, even gimpy ones, can accommodate running with good management. Remember again the evidence cited above (Williams) that runners actually get less arthritis. Because we are built to run in general, and we are built to heal.
Some people are going to find that even good knee-stress management still does not result in relief. Their capacity for running remains sharply limited. “I’m always fine until the half hour mark,” is a common scenario. “But no matter what I do, I always start hurting after that.” Is it fair to say that this patient isn’t built for running?
Even in such a case, I want to discourage that depressing interpretation, because there are still other alternatives to the structuralist view of knee pain. For instance, it may not be a matter of cursed anatomy, but of failing physiology — software instead of hardware! In cases where I am stumped by persistent knee pain, I am certainly also forced to chalk it up to unknown and probably unknowable factors. But in my case, I believe the evidence strongly suggests that it is a different sort of mysterious factor that should be considered: that there is more likely to be something about your tissue behaviour that won’t allow recovery, rather than something about your tissue structure.
If we’re stumped either way, does it matter which way we’re stumped? Of course! A better theory about why your knee pain persists could, over the years, lead to valuable refinements in how you try to manage it. Focus on a dubious theory, and you’ll be a lot less likely to make any progress. Focus on a better theory, and someday you just might succeed where you failed before. I have had many aches and pains in my life that were frustrating for a long time, until eventually they yielded as my understanding improved. So it matters very much whether you believe it is more likely to be mysterious anatomy or mysterious physiology that keeps you from healing.
GO TO TOP • CONTENTS • NOTES
One of the major myths about iliotibial band syndrome is the inflammation myth. It is not really inflamed, and several common treatments based on the myth may fail because of this. If there’s no fire, stop hosing it down!
In fact, no repetitive strain injury (RSI) is truly “inflamed” for long, if ever — not in the classic sense of the word. Inflammation at the site of an infection or injury involves very different biochemistry than what’s happening in chronically overloaded tissue, which is much more degenerative in character. True, classic inflammation is always painful and is almost always helped by anti-inflammatory medications, at least a little. But the pain of any RSI is much less consistent, and mostly unaffected by anti-inflammatory drugs like ibuprofen. Andres and Murrell in 2008:59
Recent basic science research suggests little or no inflammation is present in these conditions.
Despite this, repetitive strain injuries are still widely assumed to be inflammatory in nature. They certainly feel like they are on fire, and the assumption is often built right into the name — the Latin suffix “-itis” means inflammation, and it’s attached to the names of several of these conditions, such as plantar fasciitis, Achilles tendinitis, and supraspinatus tendinitis.
But not IT band syndrome! Why not IT banditis? Perhaps because it sounds too silly. This exception to the naming rule is not significant: there is no doubt that ITBS is mostly an overuse injury and universally thought of as “inflamed.” To find the hidden “itis” in ITBS, look no further than the assumption of tendinitis, which is now covered by layers of wrong (not the tendon, not inflamed). And if not an inflamed tendinitis? We learned above that the true identity of ITBS could well be more of a bursitis — which also isn’t inflamed. Bursitis has an even more inflamed reputation than tendinitis, and yet, even in bursae gone bad, inflammation is either nowhere to be seen or extremely minimal. According to Khan, when researchers
examined bursal tissue in patients with so-called subacromial ‘bursitis' they found an ‘absence of plasma cells and a paucity or even absence of neutrophils and lymphocytes’. These features are incompatible with true inflammatory bursitis … .
What’s really going on has little in common with classic inflammation as we know it from infections and acute lesions, where the immune system is out in full force to repel microbes, and the presence of white blood cells is the major microscopic signature. In RSIs, the white blood cells are barely there, and the scene is dominated instead by signs of tissue failure and degeneration. It’s like premature arthritis in any overloaded tissue that can’t repair itself fast enough to keep pace with the stresses placed upon it. Tissue rot! Khan et al. again (different paper):60
Numerous investigators worldwide have shown that the pathology underlying these conditions is tendonosis or collagen degeneration.
Bottom line: if there’s no fire, stop hosing it down!
The other side of the story: don’t count inflammation out quite yet
Of course it’s more complicated. There is always another layer. The idea that RSIs aren’t inflamed is based mainly on the absence of classic, acute inflammation: the clinical and pathological signs of a vigorous immune response. But there’s almost certainly more to inflammation than redness and white blood cells swarming the tissue like police trying to control a riot.61
But that is starting to change. Just because you can’t see it doesn’t mean it’s not there, or wasn’t there earlier. Maybe you just have to look better. And Dakin et al. looked better in 2017. They looked for more subtle signs of inflammation in Achilles tendinitis … and found them, seemingly without much ambiguity. Their paper in British Journal of Sports Medicine reported that painful and ruptured Achilles tendons “show evidence of chronic (non-resolving) inflammation.”62
Looking at Dakin et al.’s results, it’s tempting to just concede that inflammation has made a comeback — it was never absent after all, it was just more subtle than the experts thought. Those goofy experts! Always changing their story!
But — and this is important — the busting of the myth of inflamed RSIs remains valid in spirit, because plantar fasciitis is clearly not inflamed as most people understand it, or in ways that can be treated with typical anti-inflammatories, which are effective only for the acute inflammation that really does not exist in RSI.
So here’s the adjusted bottom line: If there’s no (acute) fire, stop hosing it down (with treaments for acute inflammation)! But maybe there are things that can be done for a bed of smoldering coals, and that idea will come up again and again for the rest of the tutorial.
If tissue is “rotting,” is there a point of no return?
More importantly, it’s important to understand that overuse could be doing more than just causing the side of your knee to burn with pain — chances are good that actual damage is being done, that tissue is actually failing, albeit slowly. It’s one thing to be inflamed — and quite another for tissues to be crumbling like old rubber. In the case of the Achilles tendon, for instance, rupture is common in the late stages of degeneration.
Fortunately, in the case of iliotibial band syndrome, the degeneration is probably not as bad as it sounds. After all, we are pretty confident that it’s not the structurally critical IT band itself that is rotting, and it is literally unheard of for IT bands to rupture — it just does not happen. If anything is degenerating, it’s the tissue underneath it. It’s unclear how functionally important that tissue is over the long term — it may be no more important than a callous on your foot, or it could be as important as the cartilage in your knee. For instance, it’s possible that the reason some cases of IT band pain are so chronic and incurable is that the tissue under the IT band decays beyond the point of recovery. Like a case of advanced arthritis, such a knee could be more or less permanently messed up. This is pure speculation, but it’s not unreasonable.
Cautious patients should probably err on the side of assuming the worst. I hope that you will find this insight inspiring and clarifying: it should encourage a significant attitude shift in favour of rest as a necessary component of treatment. It is easier to justify and accept taking it easy when you understand that stubborn overuse may be slowly destroying a bit of your anatomy.
But don’t panic either — based on the evidence we’ve already discussed, it’s more likely that the only tissue that’s in trouble is not the “structural” substance of the IT band itself, just some tissue underneath it. You don’t exactly want that to be degenerating either, but it’s certainly less alarming a mental picture than “rot” of the IT band proper.
GO TO TOP • CONTENTS • NOTES
Trigger points are so-called “muscle knots”: small patches of dysfunctional, clenched muscle tissue that cause pain and weakness. Everybody has at least a few, like pimples, yet they tend to be ignored by most health care professionals, primarily for lack of education in the subject. They can mimic, complicate, or even directly cause virtually any other musculoskeletal problem — including IT band syndrome.
Assuming they actually exist, that is. They are a little bit controversial. Not hugely. But a little.63
There are three possible ways that trigger points might be relevant to ITBS (or anything else, for that matter):
- Mimicking ITBS. In rare cases, trigger points in the quadriceps muscles may cause pain to spread into the side of the knee, which is called “referred pain” — in other words, it hurts in the same place as ITBS, but it’s not actually ITBS. This is not a common situation, but it is not unheard of, and I’ve encountered a handful of cases over the years of people who seemed to have a hot spot of pain on the side of the knee that didn’t otherwise fit the description of ITBS very well, and was effectively treated by massage of the thigh muscles — which shouldn’t work on a true case of ITBS. Particularly if combined with another minor knee problem or two, or perhaps just a bit of IT band syndrome, this kind of pain can mimic full-blown stubborn ITBS.
- Causing ITBS. Another possibility is that trigger points could be a root cause of ITBS: the chicken that came before the egg. This is really no more likely than any other totally hypothetical root cause, but it’s not impossible, and it makes for interesting contrast. For instance, trigger points could be the reason why hips are weak, which in turn is one of the other proposed root causes of IT band syndrome — not one I take very seriously, but a proposed root cause nevertheless. And yet the roots may go deeper, to trigger points. Trigger points tend to be extremely common throughout the core: the low back, buttocks and hips are all prime trigger point real estate.
- Complicating ITBS. Finally, and probably the most common and plausible scenario, muscle pain may arise in reaction to a case of ITBS, which naturally tends to make it seem worse, more stubborn, and more complicated. Treating for these trigger points may relieve some symptoms and “simplify” the clinical situation. Alert readers will notice that this problem could in principle feed back into the others: once formed, reactionary trigger points could cause ITBS-like pain and cause problems like hip weakness that actually directly cause more IT band trouble.
Despite this trinity of trouble, the role of trigger points in ITBS is probably quite limited — it remains predominantly a repetitive strain injury, more affected by overall volume of knee stress than any other factor.
Trigger points also get a mention here for a sneaky fourth reason:
- Red herring! Trigger points also routinely cause hip and thigh pain that has nothing whatsoever to do with ITBS … but still gets diagnosed that way.
GO TO TOP • CONTENTS • NOTES
Hip and thigh pain is extremely common, and nothing is mistakenly called ITBS more often than hip and thigh pain, which can be just as stubborn and baffling as ITBS. Calling it ITBS implies that it has something to do with the IT band, when in fact this kind of pain has many and likely overlapping causes, and doesn’t have much to do with the IT band specifically.
Why would anyone call hip pain ITBS? Three reasons:
- The IT band is long and crosses the hip joint as well as the knee.
- Hip pain can spread well down the thigh, as far as the knee, sometimes even beyond.
- Hip pain and runner’s knee often co-exist.
There is a link, but it’s not a strong one, and hip pain is not ITBS. Even if hip pain is partially related to the iliotibial band, it’s still not “IT band syndrome.” So what is it?
Greater trochanteric pain syndrome
GTPS is the most useful and accepted label for unexplained hip-o-centric pain: aching with an epicentre around the large bump of bone on the side of the hip, the greater trochanter of the femur. While it is usually experienced as “mainly” hip pain, it routinely involves widespread, diffuse pain throughout the entire region.
Even as far down as the knee. Hence the confusion. (At its sharpest and most widespread, GTPS is easily mistaken for sciatica.)
The greater trochanter just happens to be — just barely — underneath the top end of the IT band. This is partly why some pros mistakenly assume hip pain is an IT band issue.65
The most common cause of hip pain, especially in younger patients, is probably just the aching and stiffness associated with trigger points (which is why this topic follows the introduction to trigger points). Hips and thighs are extremely common places for trigger point pain — probably about third in line, after the neck and shoulders, and the low back.66
Many of my readers turn out to need more help with their hip and thigh musculature than they do with their knees. In fact, this is a likely explanation for some seemingly “miraculous” cures of ITBS, and especially the popularity of self-massage with foam rollers: a little massage often relieves hip and thigh pain, creating the illusion of a quick cure from a case of iliotibial band syndrome … that you never actually had in the first place.
Hip pain as a complication and partial cause of ITBS
Many ITBS patients do seem to experience some hip discomfort in addition to their (stronger) lateral knee pain. Anecdotally, that correlation is strong: easily half of ITBS patients seem to have hip and thigh pain as well. Salt in the wound. Adding insult to injury.
GTPS is not the same thing as ITBS, but it might contribute to it and muddy the diagnostic waters. For instance, grouchy hip muscles that control the tension on the IT band might make a minor contribution to ITBS — a speculative biomechanical factor I don’t put much weight on, but I’ll give it a nod at least. It’s possible.
The pure sensory contribution of hip pain is probably more important. Pain spreading from the hip down to the knee may make an existing, legitimate case of ITBS feel much louder. A patient with both kinds of pain would probably have hip and knee pain, without either one obviously dominating. If you didn’t actually have ITBS, the hip pain would dominate. But if you do have ITBS, and some hip pain, then the hip pain might be making the knee pain worse. (The reverse is less likely to be the case.67)
A vicious cycle between ITBS and GTPS might also be possible. Hip pain might well develop as a complication of the knee pain… and then feed back into the knee pain. (And again, the reverse is less likely to be the case.68) If you didn’t have hip and thigh pain when you first got a case of true IT band syndrome, then there is a chance that you do now.
Treating hip and thigh pain may or may not have any effect on a full-blown case of ITBS, but is worthwhile in itself at least. And so some of the basics of treating GTPS are integrated into the treatment options below, especially massage, and especially trigger point therapy for “perfect spots” #6 and #8. Massage is probably the best available means of treating muscle pain, and it will be covered thoroughly in the treatment sections below.
GO TO TOP • CONTENTS • NOTES
The huge majority of iliotibial band syndrome appears to be closely associated with overuse and repetitive strain. However, there are clearly exceptions.
The most common example seems to be ITBS that arises as a complication of trauma to the knee, either due to accident or surgery. Quite a few people have written to me over the years to inquire about such cases, but I have little knowledge of them — and neither does anyone else. Even typical ITBS is generally under-studied, as you’ve seen. Atypical cases like this are not on anyone’s radar, and there is simply no hard information about them that I know of. All I can do is offer a few educated guesses about why they happen and how it might affect treatment.
Trauma may simply cause new biomechanical problems and stresses, which make you more vulnerable to ITBS. In these cases, it simply takes less repetitive strain to develop a problem, but it is really no different from any other case of ITBS. There’s not really any more hope of knowing or correcting the biomechanics than there is with a normal case.
Or there might be a more exotic explanation.
Most of the time it’s hard not to heal. The body will recover from most kinds of injuries, almost no matter what — it’s just a matter of time, and you couldn’t stop it if you tried, not that you’d want to.
So why do repetitive strain injuries often seem immune to recovery? This is what makes them both terrible and fascinating. Usually the explanation for their stubbornness is just that they are never given enough of a chance to rest, or because it’s hard to rest them. (Anal fissures are the most unpleasant, vivid example of a lesion that is extremely difficult to protect. Sorry to inflict that mental image on you, but they really are a perfect example.) Dealing with that kind of scenario is what most of this book is about.
But sometimes healing fails. Pain can persist even after the tissues have recovered — a neurological malfunction. And/or sometimes tissue recovery fails altogether, even when conditions are ideal. For instance, a low but predictable percentage of bone fractures simply do not heal, and no one knows why. It’s a disturbing problem. Surgeon Robert Becker describes it:
As an orthopedic surgeon, I often pondered one particular breakdown of that [healing] energy, my specialty’s major unsolved problem — nonunion of fractures. Normally a broken bone will begin to grow together in a few weeks if the ends are held close together to each other without movement. Occasionally, however, a bone will refuse to knit despite a year or more of casts and surgery. This is a disaster for the patient and a bitter defeat for the doctor, who must amputate the arm or leg and fit a prosthetic substitute.
Throughout this century, most biologists have been sure only chemical processes were involved in growth and healing. As a result, most work on nonunions has concentrated on calcium metabolism and hormone relationships. Surgeons have also “freshened,” or scraped, the fracture surface and devised ever more complicated plates and screws to hold the bone ends rigidly in place. These approaches seemed superficial to me. I doubted that we would ever understand the failure to heal unless we truly understood healing itself.
The body electric, by Robert O Becker and Gary Selden, p. 29–30
And I have a personal example: for no apparent reason, I never healed properly from laser eye surgery. My right cornea has never recovered from being burned (while the left recovered perfectly), and I still suffer routine pain and irritation, as though the wound was still almost fresh. My surgeon is apparently one of the world’s most expert cornea specialists. The last time I saw him I asked why a cornea would fail to heal and he literally shrugged — humility, not indifference. He knows as much as anyone has ever known about corneas, but he doesn’t know why mine won’t heal.
There are actually countless similar examples in medicine. Healing of all kinds can fail, and in unpredictable ways. As Becker pointed out, we cannot “understand the failure to heal unless we truly understood healing itself,” which we clearly don’t. (Although Becker certainly found some fascinating biological clues in salamanders … which is why a salamander represents PainScience.com.) It’s fascinating that one organism can literally regrow entire complex limbs, yet we can fail to heal from a little irritation (more about regenerative medicine for ITBS later on in the book).
Salamanders have truly extraordinary regenerative capabilities — far more impressive than any other known macroscopic vertebrate. We don’t know how healing can work so well in salamanders … or why it can fail so completely in humans.
So when tissue on the side of the knee is disturbed by accident or trauma, it may not heal properly — a kind of “simulation” of a repetitive strain injury. Without knowing why the tissue refuses to heal, there’s no way to know if it will ever recover. However, this is not particularly different from standard issue ITBS, which is also an injury, and which may also not be healing properly (even when repetitive strain is removed). Screwed up healing may be exactly what makes some nasty cases so nasty in the first place.
The major difference between the two scenarios is just how they started, the speed of the tissue insult — traumatically quick, or overuse in slow-motion. With traumatically induced ITBS, you know that the knee isn’t recovering properly — that’s why there’s a problem. But with overuse ITBS, it’s an open question whether it will recover when given a proper opportunity, when the “siege” of stress is lifted. When that siege is lifted, perhaps your knee will recover quickly and thoroughly. Or perhaps it won’t. Regardless of how it started, you have to give it that chance, and so your approach to the problem is going to be roughly the same: protect the tissues as well as you can, giving them the best possible chance to regain homeostasis.
Until we learn nature’s deep secrets about how healing works, that is the best that you can do.
GO TO TOP • CONTENTS • NOTES
Portrait, attributed to Bartolomé Esteban Murillo, of Galileo Galilei gazing at the wall of his prison cell, on which are scratched the words "E pur si muove" (not legible in the original image).
Oops! I thought the science of the IT band and its movements was settled. Specifically, I had high confidence that it does not move back-and-forth across the side of the knee (causing IT Band syndrome). My confidence was based on compelling evidence that it can’t move like that — an anatomical impossibility, or near enough. And so debunking “friction” in runner’s knee became one of the mythbusting pillars of my writings on this topic.
It all seemed so clear! I really never expected any controversy about this.
And yet there is. Science seems determined to be perpetually unfinished.
Quick review: the case against IT band movement and friction
As discussed more thoroughly above, for a long time everyone mostly assumed that the IT band was irritated by rubbing back and forth over a bump of bone on the side of the knee, the lateral epicondyle. That old version of the IT band story was challenged about a decade ago by Fairclough et al in a dissection study showing that the IT band is firmly anchored to the bone it is supposedly rubbing over. Rather than rubbing, it seemed more likely that the IT band was simply compressing the tissue underneath it over and over again, and any appearance of movement was an illusion created by a “wave” of tautness moving through the fibres.
This seemed like a decisive change in how IT band should be described: for most people paying attention to it, myself included, Fairclough’s paper more or less put the idea of “friction” in ITBS out to pasture. Friction became a myth to be busted, and I busted it.
But a 2013 ultrasound study by Jelsing et al has set the pendulum back in motion again, back towards friction.69 The science of this is no longer settled.
The challenge: the case for movement back-and-forth is back
Fairclough et al. basically made an assumption that the IT band cannot move back-and-forth, based on the anatomy — a reasonable assumption, perhaps, but an assumption nevertheless.70 Jelsing et al. decided to actually properly check what happens in living subjects using ultrasound. Why not?
“In our opinion,” they write, “the well-documented fascial attachments of the ITB to the lateral femur may limit anteroposterior ITB motion but do not preclude such motion.”
And, of course — because science is just like this — they found that the IT band does move.
The distance from the anterior fibers of the ITB to the apex of the lateral femoral epicondyle decreased from the fully extended to 30° and the fully extended to 45° positions. … We have clearly documented that the ITB does in fact move anteroposteriorly relative to the lateral femoral epicondyle within the functional ranges of knee flexion-extension.
Fascinating. How inconvenient for me! So much for all my tidy, confident debunking of the friction myth.
Jelsing et al.: the results and possible problem
The study was straightforward: they used ultrasound to carefully examine 40 knees in 20 healthy recreational runners (five men and 15 women). They measured the distance between the forward edge of the IT band and the lateral femoral epicondyle, through the first 45˚of knee flexion, and found that it moved backwards .71cm on average.71
This evidence is inherently simple and compelling. I’ve read the entire paper carefully, twice now, and it’s hard to find much fault with it. It’s well-written and covers all the bases. The authors candidly acknowledge a few notable weaknesses, but none are obvious deal-breakers.72 The biggest is that “we did not specifically determine the reliability of our measurements or their accuracy relative to a reference standard.” Which is related to my own main concern …
The results depend completely on the expert observations of a single ultrasound expert, who might have been gunning for Fairclough and found what he wanted to find (evidence that Fairclough was wrong). Like all imaging technology, ultrasound really does require expertise to correctly interpret. The images are cryptic to non-experts. But experts can have selective perception too, and the history of science is chock-a-block with good examples of that.
Highlighting the general problem with interpreting ultrasound images: they knew they really need to look at the back edge of the band (more on this below), and yet it was so difficult to actually see that they were only able to measure it in 4 of 20 patients.73
And yet I doubt that’s actually what happened here. The tone of the whole paper is quite reasonable, fairly represents all key relevant points, and strikes me as an earnest attempt to discover the truth and not just to prove someone else wrong. The results certainly need to be replicated, but I wouldn’t waste my money betting against it. I suspect another examiner will find the same thing.
Could the movement still be an illusion?
Possibly. The authors themselves raised the possibility that it only looks like the IT band is moving, much as Fairclough et al. originally suggested:
Although these data clearly showed that the anterior ITB moved relative to the LFE, we did consider the possibility that this motion may not represent translation [sliding across the LFE]. It would be possible for the anterior fibers of the ITB to move closer to the LFE as a function of ITB tightening due to increased tension.
This is why they tried to look at the back edge of the band as well as the front. Was the whole thing moving, both edges together? The edge was so hard to see in most people they could only get data on it from four subjects … but in those four, the back edge did move in tandem with the forward edge. And so:
Given that both the anterior and posterior fibers of the ITB moved posteriorly during knee flexion, it is reasonable to conclude that the ITB does translate to some extent over the LFE during knee flexion.
However, just because it moves does not mean there’s friction or that the movement is clinically significant. And may still not be “sliding” at all, but moving more like the swaying of seaweed anchored to rocks in shallow water. That is, it’s not “rubbing” back and forth so much as flexing to and fro — mostly eliminating the possibility of any significant friction. If the Jelsing and Fairclough studies can be reconciled, that’s probably how.
Adding more to the credibility of this paper, the authors graciously point out that “our findings are not necessarily wholly contradictory to those published by Fairclough and colleagues,” because the anchoring of the IT band to the underlying bone may indeed limit any rubbing motion, but without completely eliminating it.
Maybe that anchor is more secure in some people than others. Maybe that’s why some people get IT band syndrome — because they have looser IT bands at that location, and there’s more friction. Anatomical variation is the norm!
Back to the IT band drawing board?
Obviously I am now going to have to reconsider and maybe eventually revise everything I’ve written above about “friction” in IT band syndrome being a myth. However, I’m not going to quite rush to actually reverse my position. The impact of this study is that the whole topic is now unsettled science, rather than settled in a new place. I was confident in what I thought I knew. Now I just don’t know again, and that’s how I’ll handle it for now. I can live with the uncertainty.
I will re-write the friction-debunking if and when more evidence makes this clearer … so it could be a while. Until then, I think the only reasonable thing to do is simply present the conflicting evidence and deal with the discrepancy as best as we can.
GO TO TOP • CONTENTS • NOTES
The tensor fascia latae (TFL) muscle.
It’s a common idea in musculoskeletal medicine that muscles can be “dysfunctional,” boosting injury risk over time, and otherwise letting us down. Dysfunction of the slightly obscure tensor fascia latae (TFL) muscle is one of the more usual suspects, often blamed for contributing to several hip and knee injuries and issues, but mostly IT band syndrome, greater trochanteric pain syndrome, and patellofemoral pain.
The TFL is blamed for IT band syndrome because, of course, it is attached to it: the IT band is the TFL’s tendon. It partially controls the tension on it, along with the gluteus maximus — and yet it’s the TFL that seems to the blame! I’ve never heard anyone attribute ITBS to dysfunctional buttocks.74
So obviously I should have written this chapter years ago. The reason I haven’t until 2021 is that the link is so speculative and weak.75
Having been blamed for causing ITBS, the TFL is often the specific target of treatment for ITBS. I have even portrayed neglect of the TFL as one of the classic common problems with IT band syndrome treatment — but really only in contrast to even more simplistic therapeutic attacks on the IT band itself, which doesn’t really make any sense at all. I actually do think it’s worth trying to make the TFL “happier,” albeit without much enthusiasm, mostly with strengthening, massage, or stretch. I only take that position because it is at least theoretically possible for the TFL to affect this knee condition.
I certainly don’t do it because the TFL-ITBS link is evidence-based!
The barely-there TFL-ITBS research
Besomi et al reviewed seventeen studies of the TFL in people both with and without several conditions.76 Eight of the studies were of the size of the TFL (“structure”), and ten were studies of its electrical activity while contracting (“activation”). They found a handful of minor, uninformative differences in these measurements — which is completely unsurprising. There are a few reasons why I wouldn’t expect such studies to shed much light on anything.
Above all, muscle “dysfunction” is an extremely poorly defined concept. Activation and size are just a couple things about a muscle that we can easily measure — “looking where the light is good”77 — but without dramatic differences they are rather unlikely to tell us anything about how well a muscle is working. There are other ways that a muscle could plausibly be dysfunctional which were not considered by these studies at all.
Also, some of these studies were looking for more implausible links with other injuries. It’s a bit of a reach to blame the TFL for anything at all, but knee ligament tears? Hip arthritis? Come on! I would be shocked if those conditions were TFL-sensitive.
But even when the research is focused on a condition with a more plausible link — like Baker et al looking specifically at a TFL-ITBS link78 — there’s hardly a smoking gun there either. They found basically nothing.
So Besomi et al reasonably concluded that the “common clinical assumptions” about the TFL’s role in injury are “not well investigated and poorly supported.” Indeed! These kinds of ideas have always just been speculative, just professionals spitballing about how muscles and joints work. Most of them have yet to be studied at all, let alone well.
There is maybe one slightly useful thing this study can tell us: there is nothing terribly obvious wrong with the TFL in people with these injuries, or it probably would have shown up in the seventeen studies reviewed. But that’s kind of like saying “if bigfoot was as tall as King Kong, he would have been found ages ago.”
Bottom line: No one really has any idea if there’s any such thing as a glitchy tensor fascia latae, let alone whether it causes injuries, and Besomi et al does nothing to confirm the idea… which isn’t surprising, because it’s really quite a reach.
GO TO TOP • CONTENTS • NOTES
It’s quite easy to diagnose your own iliotibial band syndrome. With just a few pointers, you will — congratulations! — know more about it than most professionals.79
People with obvious iliotibial band syndrome sometimes tell me that they were diagnosed with a “knee sprain,” which always cracks me up a bit. Knee sprains — ligament tears — require a traumatic incident, what I call an “oh shit” moment. When you sprain a ligament, there is no missing it! You know, instantly, that something awful has happened. This does not occur in ITB syndrome. As mentioned above, ITB syndrome may start fast, even ramping up to a high volume within a few minutes in some cases, but it cannot be as instantaneous as a trauma.80
Most non-traumatic lateral knee pain in active people is going to be iliotibial band syndrome. And it really does need to be on the outside of the knee to qualify,81 and if it actually is, it’s almost always ITB syndrome. It could be something else (and some of the possibilities are presented below), but as an old expression goes, “If you hear hoofbeats in Texas, think horses, not zebras.” And if you hear “non-traumatic lateral knee pain,” think about ITB syndrome.
However, there are several other things that can really cinch the diagnosis up as tight as your iliotibial band. (Not that tightness has much to do with it, but the analogy was irresistible.) The circumstances that breed iliotibial band syndrome are predictable … and definitive.
ITBS almost always occurs as a consequence of an unfamiliar effort in running, walking and hiking — i.e. your first big training run, your first hike of the season. It may come on quite suddenly, or gradually, but it will never be out of the blue. It is nearly always associated with hard use of your legs — or harder use than usual, harder than you’ve used them in a while.82
On the one hand, it seems a bit ridiculous to me that anyone should need to bother with an MRI to confirm a diagnosis of iliotibial band syndrome — usually the features described above are more than enough to make the call one way or the other.
On the other hand, if you have a difficult case which doesn’t quite fit the classic signs, symptoms and circumstances — entirely possible, if you’re reading this tutorial — then by all means, get an MRI. They do work.
MRI has been shown to be a perfectly good way of clinching the diagnosis.8384 It might not be such a bad idea, considering how this condition seems to be given only the most basic attention by most health care professionals. If there is chronic uncertainty about the cause of your chronic knee pain, an MRI could finally put the question to rest.
Another reason to get an MRI is to make sure that there isn’t anything else wrong with the knee that may be complicating the situation, like a cyst. Consider this case report in the journal Knee:85
We present the case of a 28-year-old competitive runner with iliotibial band (ITB) friction syndrome associated with a synovial cyst. Magnetic resonance imaging (MRI) did not demonstrate a fluid collection. However, open exploration revealed a large cyst beneath the ITB arising from the capsule of the knee proximal to the lateral meniscus. The cyst disappeared on extension. The pre-operative MRI scan may have revealed the cyst, if it had been taken with the knee flexed.
This person could easily have gone through a dozen doctors and therapists before finally getting some answers! And with no one really to blame. Note that a positive MRI was hardly guaranteed — only maybe if it had been “taken with the knee flexed.” More informally, reader Eric C. has a similar cyst story:
After struggling this for many years I finally had surgery in the fall of 2013. Interestingly, they found a cyst right below the incision. It wasn’t apparent on the MRI. They did remove the cyst and do an oval window removal of part of the IT band. I’ve just taken the winter somewhat off, doing mostly rehab and weights.
The results have been good so far. The real test will be in a few months as I slowly ramp up the hiking to see how it does … but already I can tell it’s better. My “ITBS” had progressed to where I could barely walk down any type of shallow slope without getting occasional but knee buckling stabs of pain, which is no longer the case. For instance, recently I was able to walk all around Six Flags Magic Mountain on vacation without problems. I decided to get surgery last year when I couldn’t walk across a tiny amusement park.
I’m happy to report that Eric was still out of pain when I checked back with him in early 2015. We’ll never know for sure that the cyst was the specific problem — because the surgery did more than just remove a cyst — but it seems likely.
MRI clearly cannot identify all such problems (Eric’s knee was not flexed for the MRI, as suggested by Costa et al, so perhaps that’s why his MRI did not show his cyst). But there are other issues that it might reveal. See a few sections below for a little more information about even “deeper” knee problems that MRI might be useful in diagnosing.
GO TO TOP • CONTENTS • NOTES
One of the clearest signals that you’ve got ITB syndrome and not some other knee problem is “descent pain,” which is physio-speak for “it really hurts when I go down stairs and hills.” The symptoms of iliotibial band syndrome are routinely worse when going down.86
This “descent pain” on the lateral knee is one of those things that I think of as a dead-give-away symptom. If you experience more pain going up hills than down them, you probably have something else.87
With milder cases, runners may or may not notice whether the pain is worse descending or ascending, but simply remember that hilly routes are generally a problem. A test on a long or especially steep hill will usually reveal that going down is the painful part! For those that live in high-rise buildings, it’s particularly easy to test: just take an elevator ride to the top, and then walk down 20–30 stories … if you can get that far.
GO TO TOP • CONTENTS • NOTES
A lot of runners with hurting knees have started reading up on their syndromes, and are not sure whether they’ve got the patellofemoral flavour, or the iliotibial. Patellofemoral syndrome and iliotibial band syndrome are extremely common (and fairly similar) injuries for anyone who uses their knees a lot, so I spend a fair amount of time ‘splaining the difference.
In a perfect, neat, and tidy world, it’s actually very simple: PFPS makes the front of your knee hurt, and ITBS makes the side of your knee hurt. Now, if only the world were perfect and neat and tidy.
In practice, of course, people with knee pain rarely have well-behaved symptoms that stick to just one spot. Both ITBS and PFPS have the potential to produce atypical symptoms. Generally speaking, there will still be a clear and identifying epicentre of pain on either the side (ITBS) or the front (PFPS) of the knee. But symptoms often do spread from the epicentre where they “should” be into other parts of the knee. There are at least two clear reasons why this would happen:
- As discussed above, muscular trigger points are probably involved as both causal and complicating factors in both conditions. And spreading, erratic pain is what trigger points do best. With nasty muscle knots in the hips, hamstrings and/or quadriceps, virtually any kind of knee pain is possible. It will not usually be as acute or focused as the core PFPS or ITBS tissue irritation … but it can be plenty bad enough to confuse things.
- The two conditions are probably biomechanically related. The ITB probably has direct anatomical relevance to patellar tracking problems — that is, the ITB is crucial to lateral knee stability, and when tight may actually pull the patella laterally. In fact, given the close working relationship between the ITB and the patella, it seems quite surprising that the two conditions rarely co-exist. Nevertheless, there have got to be ways in which the ITB affects the patella and vice versa.
In cases where it’s hard to tell the difference between the two conditions, this comparison checklist will help you nail it down:
|Instructions: check all that apply. The condition with the most check marks wins! This is not a form — you do not have to “submit” it. Just use the check boxes for visual reference.|
|Iliotibial Band Syndrome (ITBS)||Patellofemoral Syndrome (PFPS)|
|The epicentre of the pain is on the side of the knee. Symptoms may occur nearly anywhere around the entire knee, particularly in severe cases, but the worst spot has to be on the side of the knee.||The epicentre of the pain is somewhere under the kneecap. As with ITBS, symptoms may occur nearly anywhere, but it must be mainly on the front of the knee under the kneecap.|
|There is a spot on the side of your knee, right around the most sticky-outy bump, that is sensitive to poking pressure, and your kneecap is not particularly sensitive when pushed firmly straight into the knee.||It’s not very comfortable pushing your kneecap straight onto your knee, but there is no particularly sensitive spot on the side of your knee.|
|Pain tends to be worse when descending stairs or hills.||Pain tends to be worse when ascending stairs or hills.|
|Started while going downhill.||Started while going uphill.|
|Both PFPS and ITBS can start over the course of a few hours or a day, but ITBS almost always does. If the pain started relatively quickly, check this box.||If your pain grew relatively slowly, over months or years, check this box.|
|Doing a deep knee bend does not especially hurt.||Doing a deep knee bend hurts.|
|Pain is not particularly affected by sitting, although it might get worse after sitting for quite a while (longer than an hour).||Pain is quite clearly aggravated by sitting with knees bent. When you get up, it hurts more than it did when you sat down.|
|You do not have any obvious structural problems in the legs.||You are a little knock-kneed, have flat feet, or your kneecaps seem to be at a funny angle.|
|If this column has more checks, congratulations — you are probably reading the right tutorial!||If this column has more checks, you may be reading the wrong tutorial! Read the introduction to the patellofemoral pain syndrome tutorial.|
GO TO TOP • CONTENTS • NOTES
Sorta. In a way. But mostly no … not really. In fact, hip pain is excluded by definition.
This section is redundant review — I already introduced hip pain thoroughly above, while discussing the nature of the beast — but I want to review exclusively in terms of diagnosis. I cannot overstate how often people are confused about this point, so I think it’s worth covering as thoroughly as possible. To recap…
A hip pain cannot be called ITBS any more than you can have a headache in your elbow. Too often you will encounter professionals who diagnose hip pain as ITBS, but it simply isn’t correct.
Unexplained hip pain is not ITBS but GTPS — greater trochanteric pain syndrome — and it can have many causes. GTPS might make some contributions to ITBS, or emerge as a complication of ITBS, but it is not the same as ITBS.
The most likely important link between them is simply that hip pain can probably spread down to the knee, adding to any knee pain that is already there — adding insult to injury.
So they may well go together, but hip pain on its own should never be diagnosed as ITBS.
GO TO TOP • CONTENTS • NOTES
Yes, there could be. A problem inside the knee joint — and intra-articular problem — can mimic ITBS. Chances are good that it won’t be a perfect mimicry, and there will be something that “gives it away” as another condition. However, it’s all too easy to miss something like this and go for a long time with a case of a not-actually-ITBS without ever being the wiser. One of my physician readers emphasized the potential for confusion:
I have practiced medicine for 50 years and have missed the diagnosis of a cracked lateral meniscus that was eventually picked up on an MRI.
How likely is this? Muhle et al used MRI to find three meniscal tears in sixteen patients with clinical signs of ITBS.88 Michels et al found four intra-articular problems out of the 35 knees they investigated: one case of femoral cartilage damage, two mensical tears, and a knee with some “gravel” in it — a “calciﬁed loose body.”89
On the one hand, that seems like a lot: in Muhle’s study, 18% of people with the symptoms of ITBS had meniscal tears. In Michels’, 5% had tears and 5% had some other problem. Yikes! Practically one in five.
But, on the other hand, remember that minor internal knee problems are common and not necessarily much of a problem. Meniscal tears in particular are often asymptomatic, or cause only painless symptoms (i.e. a little clicking and nothing else). You could easily have a little meniscal tear that was causing you no symptoms whatsoever, or only minor symptoms … and which may have nothing to do with your iliotibial band syndrome.
So, what we really want to know is: how many people with ITBS have a meniscal tear that is actually causing ITBS-like symptoms? Probably not very many, but unfortunately, nobody has a clue one way or the other. All we can take from the science so far is that it’s certainly possible, but not particularly likely.
In difficult cases, the possibility of another, deeper knee problem can be addressed by MRI and arthroscopy. This will be discussed below in the surgery section.
GO TO TOP • CONTENTS • NOTES
A “wonky kneecap” diagnosis is commonly used to dubiously shore up a diagnosis of iliotibial band syndrome — which is usually unnecessary, because we can diagnose ITBS quite well without examining any kneecaps at all.
The idea here is that a crooked patella is a sign of a tight IT band. In one popular theory, a tight IT band must drag the patella out of alignment by pulling hard on the side of the knee. Since the IT band blends into the entire lateral knee joint capsule, it does seem reasonable that an unusually tight IT band could be yanking the kneecap to the outside. And there probably are a few cases of ITBS co-existing with an obvious patellar alignment problem.
However, we’ve already determined in this tutorial that IT band “tightness” may be something of a red herring, either meaningless or not terribly meaningful: a factor, perhaps, but not the main factor. In practice, kneecap alignment doesn’t seem to be involved much in ITBS. I know this because lots of people have ITBS, but many have not the slightest trace of a poorly aligned patella.
And a serious problem with basing diagnosis or therapy on the idea of misalignment of the kneecap: therapists cannot agree on the location of people’s kneecaps!
Examination of kneecap position is a reflex for most manual therapists — a staple of knee pain diagnosis, as inevitable as a doctor asking you to say “ah.” Kneecap alignment is almost universally regarded as a sign of patellofemoral pain syndrome and patellar instability, and accurate assessment of knee position is essential for meaningful taping (a popular treatment method for most kinds of knee pain). Obviously you can’t use tape to align a kneecap if you don’t know how it’s misaligned to begin with.
But is accurate assessment of patellar alignment actually reliable? Turns out probably not. As with so many other eyeballings of biomechanics, the same patient is likely to get different diagnoses from different professionals. In fact, a 2009 paper in Manual Therapy reviewed nine reliability studies of 306 knees.90 What evidence there is showed that assessment of patellar position was “variable” from one therapist to the next — if you get a bunch of clinicians to assess the same kneecap, they will come up with different diagnoses.91
Despite these problems, poor patellar tracking continues to be used as evidence of a tight IT band, and then used as a justification for probably time-wasting and money-wasting therapies and therapeutic exercises. Elaborate and tedious work to try to “align” kneecaps are almost as common as the testing procedure itself. Take your hurtin’ knees to a manual therapist, and odds are excellent that they will not only conclude that you have an alignment problem, but also that you need therapy and exercise to fix it.
If you’re doing a bunch of therapy based on the idea of patellar misalignment — and I mean both patients and professionals — you should reconsider it.
GO TO TOP • CONTENTS • NOTES
Medical ignorance of sports medicine (see Stockard) has exposed me to some bizarre tales of misdiagnosis and mismanagement of iliotibial band syndrome. I don’t want to pick on the doctors specifically about this — by no means are they the only offenders — but all of three of the disturbing examples I have on file here involve doctors (in addition to a supporting cast of other kinds of professionals).
The first concerns a young woman in my care who was told that she had iliotibial band syndrome. She was prone to muscle pain — she was getting trigger points the way some teens get acne, a frustrating situation, but apparently benign — and I often reassured her that there was probably no more ominous cause of her pain. But she was constantly (understandably) looking for some other explanation for her discomfort. There must be, she figured, something broken or torn or inflamed. Even though she was in otherwise excellent health, took good care of herself, and did not participate in any athletic activity to excess, she tended to assume that she must have hurt herself in some way. Such fears often exacerbate pain.
This psychological dimension to her problem was quite prominent. It was heartbreaking to see her constantly worrying whether some harmless activity had damaged her! It made it hard for her to enjoy things, more difficult than the symptoms alone would make it. But if it were that easy to get injured, no one could leave the house. Whatever was causing her to have so many minor sore spots, it wasn’t not an injury … and it certainly was not iliotibial band syndrome.
So I had been working with this woman, and half my job was calming her down. And then one day she came in and announced that she’d been to the doctor about her pain, and before she even told me anything, I thought, “Uh oh.” You see, doctors too often scare people with speculations about possible causes of pain … and I’d been trying to calm this client down for weeks. Sure enough, she announced in a firm I’ve-got-this-figured-out now voice, “My doctor says I have iliotibial band syndrome.”
Ridiculous. There are any number of things I could have missed, which a doctor might have diagnosed. But not that.
Medical diagnosis of body pain is often so wrong that is seems disconnected from reality. I find myself thinking uncharitable thoughts about such doctors, things like, “Was he high?” and “Did she get her credentials by mail order?” But this diagnosis was particularly impressive in its irrelevancy, its drunken-game-of-darts inaccuracy.
That patient had erratic aches and pains in every part of her lower body. Back pains, hip pains, leg pains, knee pains … shifting by the hour, by the moment, like evil aurora borealis in her muscles. She has ascent pain in the knee, not descent pain that would indicate ITBS. Her knee pain was far from her most prominent problem, and when she got it, it was on the front of the knee … not the side, which is necessary for an ITBS diagnosis by definition (as I have now mentioned at least a half dozen times, because it cannot be said enough). She had no history of long distance running or any activity that would cause iliotibial band syndrome, no history of developing knee symptoms during any kind of activity that might cause iliotibial band syndrome. And then she had a mixed bag of other symptoms, typical for fibromyalgia or myofascial pain syndrome, but entirely unlike anything iliotibial band syndrome should ever cause.
The diagnosis was as wrong as if the doc had mistaken acne for smallpox.
Yet there she was, standing before me, desperate and deeply distracted by this wrong idea. Clients with unexplained, widespread pain often crave the solid ground of a concrete injury diagnosis, and who can blame them? And the doctor had played right into that, his authority to validate a bizarre red herring of a diagnosis. It took most of a delicate, diplomatic hour to talk her down … time that could have been spent in many better ways.
GO TO TOP • CONTENTS • NOTES
Here’s another good one from the “d’oh” files. This one is a tale of serial misdiagnoses: a string of health care professionals diagnosing non-existent ITBS, one after the other, each one’s failure to see the reality of the situation all the more amazing in light of the failure of the previous therapy attempts.
Natalie Baxter Strange, of Norwich, England, managed to go through sixteen months of pain and attempted therapies for ITBS without any one of six different health care professionals ever so much as hinting that ITBS was a garbage diagnosis — wrong by definition, wrong like calling shoulder pain a knee problem wrong — not even the right body part.
She saw a general practitioner, a sports physiotherapist, another sports physiotherapist, an acupuncturist, another physiotherapist, a massage therapist, and a personal trainer who “specializes in remedial weight training.” (Natalie points out that her massage therapist was not asked to diagnose.) That’s at least six professionals who should have known better — while Natalie continued to have pain that never significantly responded to any therapy for knee pain. Every single one of them either confirmed or went along with the ITBS diagnosis.
But here’s the strange part: Natalie Baxter Strange did not have knee pain.
“I have started to have knee pain,” she told me on the phone. “Just in the last two or three months. Mostly I have hip pain. It’s always been mostly a hip problem. Sometimes it spreads down the thigh, along the iliotibial band.”
Hence the confusion. The pain was near and sometimes overlapping the iliotibial band, and this infamous anatomical structure with its very own syndrome apparently attracted their blame. They could just as well have fixated on an incorrect hip pain diagnosis like bursitis or sciatica … but they chose iliotibial band syndrome, because the pain seemed to be on the iliotibial band. But — as you should now be tiring of hearing, and know better than the health care professionals that Natalie was “helped” by — iliotibial band syndrome is, by definition, a painful condition on the side of the knee.
I asked her if she had ever felt, even recently, that the pain was primarily on the side of the knee?
“No,” she confirmed. “I have never had strong lateral knee pain.”
GO TO TOP • CONTENTS • NOTES
Here is a third and final story of terrible knee pain diagnosis.
TJ McMorrow is a young running star. With a state-wide competition just three weeks away, his mother Annette contacted me, a bit desperate, because TJ’s training had been brought to a halt by a pain problem, allegedly iliotibial band syndrome. This story gets “daft diagnosis” status because of his doctor’s deeply flawed logic. Annette wrote:
“The doctor said his X-rays showed a perfect set up for IT band due to the sharp turning in of his hip, as opposed to most that have a more gradual turning in.”
A couple of physiotherapists had not contradicted this and were treating him as an ITBS case.
And yet, just like Natalie Strange, it turns out that TJ didn’t even have knee pain. “TJ’s main source of pain is not his knee, it’s his left hip,” his mother confirmed initially, and then again more emphatically a few days later, “I verified with TJ that he has no knee pain at all.”
Diagnosing ITBS by X-ray is absurd. It’s not an X-ray-able condition. It’s like diagnosing the flu by X-ray. It’s completely ridiculous. It’s simply the wrong tool for the job. If the doctor knew the slightest thing about the condition he had named as the problem, he would know that.
But the absurdity of an X-ray diagnosis is topped by referencing a single biomechanical factor … and not just any biomechanical factor, but an anatomical variation that isn’t even one of the standard biomechanical problems this problem gets blamed on. What a spectacular example of the foolishness of structuralism!
And, unfortunately, the misfortune of this story was compounded by a fairly typical scenario — although I was easily able to persuade Annette herself that the diagnosis was wrong by definition, she was unable to persuade anyone else involved. The last I heard, her son’s coach, her husband, and her son were all still determined to proceed with ITBS treatment, with a knee steroid injection planned … in the absence of knee pain!
And there are many more such stories
Sadly, these kinds of stories are not isolated incidents, and the scale of the misdiagnosis problem is quite shocking. Although these are best-of-breed examples, I have heard many others from patients, and readers around the world. This is just the typical level of “expertise” you can generally expect on the subject of iliotibial band syndrome.
In the examples above, IT band syndrome was diagnosed in its absence, but there are horror stories in the reverse: true cases that go undiagnosed. Imagine that you actually have iliotibial band syndrome — and, hey, you probably don’t have to imagine it, if you’re reading this! You have the real McCoy, and off you go to see a professional. Ironically, despite the more common predilection for diagnosing iliotibial band syndrome when it is nowhere to be found, odds of failing to diagnose genuine IT band syndrome are also quite high.
Multiply the diagnostic incompetence by the hundreds of thousands of professionals throughout those parts of the world where running and cycling are popular (which is quite a lot). How many athletes have been misdiagnosed, misled, mistreated? How is it, this late in medical history, that such a relatively minor diagnostic challenge can still be such a mess?
Iliotibial band syndrome is an incredibly common condition, simply because of the popularity of running. Every year I watch several tens of thousands of Vancouver runners stream past my house for the annual Vancouver Sun Run. The math of it is impressive: a significant number of them probably either have this knee problem already … or will by the end of the race! That’s quite a few cases. Sadly, few of them will receive appropriate advice.
It’s not a medical issue on the scale of cancer or heart disease, but it ain’t nothing. That’s a lot of troubled knees. If you add up all of the incompetent musculoskeletal health care out there, including the truly staggering economic costs of back pain, and it’s surprising that our civilization can progress at all.
GO TO TOP • CONTENTS • NOTES
There aren’t many things that IT band syndrome can get confused with (other than patellofemoral pain syndrome, already thoroughly discussed). Most of these are unlikely misdiagnoses. That will mostly be the theme of this section: in each case, the question “Could it be … ?” will best be answered with “probably not.”
Still, it’s wise to be thorough, and it’s unwise to underestimate just how far wrong ITBS diagnosis can go. This first item, popliteal artery92 entrapment, was pointed out to me by a physician reader. When I told him that I couldn’t recall ever encountering any diagnostic confusion on this point, he replied:
Most physicians are not astute enough and lack the clinical expertise to tell the difference between popliteus syndrome and IT band syndrome.
Oh, dear. I hate to think that a physician wouldn’t be able to tell the difference between a calf that’s dying for lack of blood and lateral knee that’s irritated by overuse. That seems almost too cynical about the state of musculoskeletal health care even for me. Almost! So, here you are …
Could it be popliteal artery entrapment syndrome (PAES)? Probably not. This is an uncommon problem, and one not much like ITBS. A large artery passes through the soft hollow behind the knee, and sometimes it is pinched off by an anatomical deformity and/or scar tissue that forms in response to an overuse injury — so it can be provoked by running. Obviously it doesn’t completely shut down the artery, or you’d lose your leg below the knee (tragically, that does happen to some people, but if that was your problem, you wouldn’t be reading this). Instead it just causes severe pain, and gives you an obviously pale and cold calf.
There is another structure behind the knee that can do a better “impression” of IT band syndrome.
Could it be popliteal tendinitis? This condition is rare, but it probably more closely mimics IT band syndrome than any other condition described here. The popliteus is a tiny muscle in the back of the knee. One end of it attaches to the side of the femur — right close to where IT band syndrome occurs. Irritation of this tendon may be superficially indistinguishable from IT band syndrome.
So what’s the difference? The trick to telling them apart is that the small popliteus muscle has a specific and finicky job to do, so you can provoke pain by resisting knee bending while the lower leg is rotated outwards — awkward but exact.93 If that motion particularly hurts, you may have popliteal tendinopathy, not IT band syndrome. Also, though popliteal tendinitis will be irritated by activity in general (like any tendinitis), it probably won’t be so distinctively bothered by going down hills, the way ITBS is.
And now for one more tendon in the area …
Could it be biceps femoris tendinopathy? Biceps femoris is the lateral hamstring muscle, which attaches well below the bulk of the knee on the head of the fibula (a small bony projection on the side of the upper leg), which is usually where it hurts. This injury could be mistaken for IT band syndrome briefly because of its lateral-ness, but in the end it should obviously be too low and/or too far around to the back of the knee, and too sensitive to hamstring contraction specifically.
Could it be a lateral collateral ligament sprain? Unlikely. This is the ligament on the side of the knee. The locations of ITBS and LCL sprain certainly overlap — but that’s where the similarity ends. Tearing a ligament is a trauma that requires considerable force: it would happen suddenly and nastily, difficult to confuse with IT band syndrome. Even though ITBS can come on surprisingly rapidly, it’s still not abrupt the way ripping a ligament is.
A few other possibilities, all relatively unlikely and needing only a few words of clarification. Could it be …
- Degenerative joint disease, arthritis? Arthritic pain probably would never be limited to the classic IT band patch on the outside of the knee.
- Lateral meniscal tear? This injury is usually traumatic, with pain a little too low for ITBS, and often accompanied by other symptoms like locking and clicking and clunking.
- Referred pain from lumbar spine? Possible, but rarely limited to a single well-defined spot like ITBS. Likely there would be other symptoms as well.
- Stress fracture? — Possible, but very rare in the lateral femoral condyle, which is the only area that would likely be confused with IT band syndrome. Stress fractures probably more sensitive to jarring.
GO TO TOP • CONTENTS • NOTES
Knees are noisy. Even cat knees.
For twelve years I was step-dad to my wife’s lovely cat. She was a cat that defied stereotypes: she had none of the aloof disdainfulness for which cats are notorious. She was charismatic, amiable, even polite. (This isn’t relevant to knee noise, I’m just adding colour, and I miss her.)
And her knees were noisy for the last several years of her life. Everywhere she went: snap, crackle, pop! You could hear her coming.
And so it is for me now as well. If I do a set of squats, the neighbours can probably hear it — every second or third squat! It sounds like there’s kindling in there.
What the heck is going on? And does it have anything to do with knee pain?
Science reports what every pro knows
Robertson et al interviewed eleven patients with knee pain and crepitus — joint noise — as one of their symptoms. They reported their impressions and concluded that:
- people don’t like it
- they believe it’s related to the cause of their pain
- they try to avoid it by moving differently
Eleven patients! I got this from my readers eleven times last week. But it’s nice to have the formal confirmation. (But why is it that science seems to either confirm the obvious or it’s hopelessly complex and conflicted? Someone should study that.)
Clunking and grinding are another matter
Snaps, crackles, and pops are one thing — clunking and grinding, especially paired with other more “mechanical” symptoms like locking and instability, is much more likely to be a symptom of frayed mensici, the noise of a joint that’s having trouble moving properly.
Ordinary joint noise is mostly just clinically uninterpretable, especially knee noise. The knee is just a naturally noisy joint, and it does not correlate well with problems at all. So you can be in trouble ... silently. And you can be fine... noisily.
And the latter is more common. A lot more common. Practically every knee that is more than 30 years old starts to get noisy, without any pain involved. Even with noise being much more common in painful knees, the painful knees are relatively rare, greatly outnumbered by noisy-but-happy knees.
Women with noisy knees are four times more likely to have the other runner’s knee, patellofemoral pain.94 (There is no equivalent data for ITBS, but PFPS is a decent stand-in for our purposes here.) So there’s some kind of link between joint noise and PFPS, but it’s not an important one: the noisy-kneed women in this study were no worse off (or better) than the quiet-kneed. Crepitus is probably a harmless side effect.
Joint noise may be a side effect of pain and/or inflammation
Joints seem to pop more loudly, and more often, in painful and injured areas. This has never been formally observed, as far as I know — it’s my own clinical observation. It may not be true. If it is true, it’s unexplained. Example: in February 2010, my wife was in a terrible car accident — while travelling alone in Asia no less — and she had a great deal of healing to do afterwards. One of the most obvious effects of the accident was a spectacular increase in joint popping, especially in her spine near her crushed vertebra. It was quite impressive. She had never really popped her spine before the accident.
This phenomenon underscores the fact that no one really knows what the $!#@&! joint popping actually is, despite some commonly floated theories95 and fascinating observations.96 Certainly no one knows why it might increase in the presence of pain and trauma, but my guess is that there’s biochemistry involved — inflammation probably affects the phenomenon.
Chances are good that painful knees crack more because they are hurting, and not the other way around.
Note that cracking is probably not hazardous in and of itself. In 1998, Dr. Donald Unger won an “Ig Nobel Prize” for diligently cracking the knuckles of his left hand only — never his right — every day for more than sixty (60) years. What did he find? “There was no arthritis in either hand, and no apparent differences between the two hands.… there is no apparent relationship between knuckle cracking and the subsequent development of arthritis of the fingers.”97
GO TO TOP • CONTENTS • NOTES
The worst case scenario is permanent, debilitating knee pain — but fortunately, that nightmare scenario is truly rare. Because of the prominence of this tutorial, I do get mail from readers who are in that position — veterans of the condition who scour the internet for more and better information in the hopes of a cure — and their stories are genuinely alarming and tragic. But they really are rare.
Research shows that, in the vast majority of cases of ITBS, its bark tends to be worse than its bite, and even the most stubborn cases are usually treatable.
But swinging back to the bad news again, iliotibial band syndrome can bark very loudly and persistently indeed: the pain can easily stop you from running. With ordinary conservative therapy, some runners will be back on the road within three to six weeks, but many will take two to six months to recover enough to run competitively.98
These are not encouraging figures: for a serious runner, even a moderately stubborn case that causes the loss of perhaps three training months is an unpleasant scenario. Not as bad as permanent injury, of course, but pretty bad. And because so many people receiving conservative therapy actually heal rather slowly suggests that conservative therapy — as already discussed — could well be a waste of time and money. But at least the condition does more or less end, eventually, for most patients.
Clinical experience has shown time and time again that many frustrated runners can take even longer than six months. Especially when you get poor advice in the early stages, rehabilitation has the potential to really drag on, and of course a few of these serious cases turn into virtually permanent problems. Patient reports like these are the exceptions, but they aren’t rare enough, in my opinion:
I have been suffering with IT band syndrome for over 3 years with no cure. I’ve spent over $8000 trying to treat my problem. I’m a runner and I miss my long runs — I can only go for about 40 minutes before the pain starts.
Stephanie MacDonald, runner, Edmonton, Canada
I’ve had constant ITBS pain in both knees, pretty much 24/7, for five years on. Sitting at my desk writing this, the knees are hurting. Tried stretching, pool running, deep tissue massage, orthotics, heel lifts (correcting leg length discrepancy of ~1 inch), etc. etc. for the first 3 years of the injury. For the last 2 years I’ve admittedly been real lazy and have almost given up! Exercise is now limited to light cycling and skiing (which if done correctly doesn’t hurt too much). I was a very competitive runner and tennis player before the injury and want to get back to exercising.
Christopher Berry, competitive long-distance runner, United Kingdom
I was a wrestler in high school and college, and to keep up my competitiveness over past 10+ years (I am 37), I took up running and more recently triathlon. Long story short, I came down with a bad case of ITB training for a 2001 marathon, after a podiatrist taped my foot for a subluxation of cuboid, and I continued to train. Anyway, after physical therapists, chiropractors, several doctors, arthroscopy, etc … I had my first “martens” procedure in April of 2003.
Jeremy Friedman, triathlete, New York
Unfortunately, Jeremy’s story didn’t end there. Although his surgery got him pain free for three years, the condition came back in late 2006. And a second surgery had significant complications, causing an “exceptional” amount of scarring, according to his doctor. “My ilitobial band virtually disappears into this mass of tissue (doctor says it is adjacent to band, but you wouldn’t know looking at my leg).”
I don’t share these stories to be scary, of course, but simply to express the full range of possibilities. Some cases are severe. Although (as you will see below) surgery is usually effective and remarkably free of complications, sometimes there are complications. It’s important to know this as you evaluate your options, and of course it suggests the need to be proactive and do what you can to prevent ITBS from persisting. I sincerely hope that your case of ITBS is not so serious, and this section is just a curiosity to you.
Another sobering reality for ITBS sufferers, regardless of the severity of your case: this condition can also go dormant until your next big hike or run, or wait even longer to revisit you. I am not aware of any hard data about how common recurrence is. However, my clinical experience and exposure to reader reports like this have certainly led me to believe that it happens quite a bit.
I have a very stubborn case that took 7 months to “go away” for just a few weeks, and now seems to be rearing its head again. I hate not being able to hike, bike, or sometimes even walk … .
Lanina Spencer, Lincoln, CA
Most recurrences are no more serious than the original. If you had mild ITBS to begin with, chances are that you will have relatively mild recurrences. However, even relatively mild ITBS symptoms, if they recur frequently, can really be a problem. I have seen runners retire from the sport, not because their iliotibial band syndrome would not resolve in the short term, but because it just kept coming back with every major effort.
The only defense against recurrent iliotibial band syndrome is to continue to train carefully, take preventative measures, sometimes rather heroic ones, and even then your safety can hardly be guaranteed. You can go for months or even years without noticing it, only to have it flare up again at the worst possible time.
GO TO TOP • CONTENTS • NOTES
Although this condition primarily affects runners, it also particularly affects hikers — usually striking rather inconveniently on the way down a mountainside. Many a hiker has gotten into trouble trying to come down a mountain as a new case of iliotibial band syndrome gets started, or an old one flares up. Hikers who have a history with iliotibial band syndrome should definitely be aware of this, and leave enough time for a slow descent.
GO TO TOP • CONTENTS • NOTES
You crazy runners often ask me this, and often insist that you’ll do anything to get better except stop running. This is kind of like saying that you’ll do anything to stop your headache as long as you can carry on banging your head against a brick wall. But — oddly enough — sometimes it actually makes tactical sense for a runner to push through the pain of iliotibial band syndrome … and you can get away with it.
There are no truly serious risks, like you have with, say, shin splints. Never try to run through shin splints — danger, Will Robinson! Shin splints are the perfect contrasting example, because there is real danger involved in pushing your luck.
The stakes aren’t so high with most other overuse conditions. While I don’t exactly recommend it, I have to admit that serious harm to your knees is unlikely. I’ve done a little running through iliotibial band syndrome myself. It can hurt a lot — probably enough to stop your foolishness, no matter how hard core you are. And it will probably become three times harder to get rid of your ITBS — and three times more likely to be a problem in the future.
But, no, you won’t “blow” your knee. Your iliotibial band will not snap (like Achilles tendons actually do), and your knee will not break. So if you absolutely must run the next marathon … knock yourself out. I’ve seen runners do this with both iliotibial band syndrome and plantar fasciitis, two common and painful conditions, and more or less get away with it — recovery was slow and difficult afterwards, but they thought it was a fair trade. If you can handle the pain, it’s not impossible. And if there’s one thing runners are good at, it’s handling the pain!
(But I repeat, do not even think about doing this with shin splints — that is a very different scenario.)
But don’t kid yourself that it’s risk free. Your IT band may not snap, but — disclaimer, disclaimer, disclaimer! — you could nevertheless do damage that cannot be undone. I already covered this while explaining the implications of “rot” above in the inflammation myth section, but it’s a pretty important point to repeat: although structural integrity is not at stake, the nature of repetitive strain injury is the slow but steady degeneration of stressed tissue, which may be irreversible past a certain point. The “padding” under the IT band could be destroyed by long-term severe ITBS. This could even explain some severe ITBS chronicity.
At present, this is just reasonable speculation. There’s no way to know if your ITBS has progressed to some point of no return, like with bone-on-bone arthritis. The risk goes up with age and duration of pain — the longer you’ve had the problem, and the older you are, the more concerned you should be about the possibility of irreversible damage. I can imagine a 60-year old marathoner with a 20-year history of intermittent ITBS pain deciding to either (a) avoid running through the pain (skip a marathon) because of the risk of permanent damage and the desire to keep running for many more years, or (b) choosing to run through for one last important race and then hanging up the shoes.
Risk tolerance is an intensely personal matter. All I can do is inform you that it certainly seems possible that ITBS could become irreversible, at some unknowable point.
GO TO TOP • CONTENTS • NOTES
As all chronic iliotibial band syndrome patients know all too well, most people — the lucky majority — recover with only a little rest and maybe some “Vitamin I” (ibuprofen). But this tutorial is for those of you who are failing to heal on schedule — for patients who are determined to heal, but for whatever reason are not able or willing to try the more invasive options like steroid injections or surgery, or not yet, at any rate. For your sake, I have assembled here the most detailed set of treatment and self-treatment suggestions for iliotibial band syndrome available anywhere that I know of. The rest of the tutorial is devoted to detailed discussions of treatment options, many of which you haven’t tried or considered yet, and some of which — I can almost guarantee this — that you probably haven’t even heard of before.
And yet none of these options is any kind of a sure thing. Although some are promising and worth trying, none of them — not one — actually work well enough to be considered truly “effective.” (If they did, this tutorial would not need to exist!) I cannot state strongly enough that treatment for IT band pain is still in the dark ages. We simply do not know with any real confidence what works and what doesn’t. So the answer to the question “What works?” is disappointing: almost nothing for sure. Even the new surgical options for ITBS, which may be a great improvement, are still too new and experimental.
Possibly, most people who recover from IT band pain would have done so with or without any treatment other than resting. And there’s probably no way to accelerate healing from this condition — just management and damage control options.
However, in my experience, most people with a stubborn overuse injury, people who have supposedly “tried everything,” often have not — in fact, many people who say that have really only scratched the surface. In particular, very few have actually taken resting very seriously. Well-planned rest for a month, perhaps combined with a few of the other suggestions here, and some of these “incurable” cases turn out fine — not due to any therapeutic miracles, but simply by talking people into actually doing the basics.
Here are the most interesting or important treatment options for IT band pain, tightly summarized. The rest of the tutorial is devoted to reviewing them, and many others, in much greater detail. Many are unique to IT band pain, and I will review those more thoroughly. Many other treatment or management approaches are applicable to nearly any chronic painful condition or overuse injury, and in those cases I will usually summarize and then link to another article on the site.
- Rest is the first line of defense for any overuse injury: it may be the only thing that’s required, but it’s definitely required. It’s also logistically trickier than most people realize. For instance, “relative rest” is a very useful concept that many patients and professionals need to understand better: most people, especially athletes, need creative exercise alternatives while healing.
- Tinkering with running technique is a popular way to try to save yourself from ITBS, but it’s impossible to know what will work, and significant technique modifications usually expose you to new risks. I particularly dismiss barefoot/minimalist running as a fad, for instance, but I do recommend some simpler modifications to how you run: it’s worth avoiding slow pace running and getting away from running on hard surfaces.
- Shoes and orthotics are mostly irrelevant to ITBS — either they don’t make a difference, or they make a difference that is so modest and unpredictable that it’s not worth much. On the other hand, they are reasonably safe and cheap, and not ridiculous to imagine that they could make a difference for some people. They might help with a gait or postural issue that might be a minor factor, and there is one type of unusual running shoe design I tentatively recommend.
- Surgery is a surprisingly strong option. You should be aware of the excellent evidence showing surgery really can work quite well. Do not reject that option carelessly — ITBS surgery is just about as good as surgeries for problems like this get.
- Corticosteroid injections are a difficult option to assess: an awkward mix of real risks and uncertain rewards. There are good reasons to believe that they may help, as well as good reasons not to get them if you can get better without them. No clear recommendation is possible at this time, for this or any other condition.
- Ibuprofen or other NSAIDs (non-steroidal anti-inflammatory drugs) are weak self-treatment options with low biochemical relevance to not-really-inflamed overuse injuries — and yet they are probably still worth trying because they are fairly cheap and safe. The emergence of Voltaren® Gel as an effective NSAID delivery system — just rub it on! — is of particular interest because it is less risky and more effective than oral medication. In contrast, Traumeel is a particularly popular ointment surrounded by major controversies for good reasons — not recommended.
- Icing can’t “cool” the heat of a knee that isn’t really hot with inflammation, but it might control pain and stimulate tissue healing and homeostasis. Contrast bathing (hot and cold) may be helpful in the same way. Unproven and underpowered — but also cheap, easy and safe — these options are “must try” treatments before you resort to injections or surgery.
- Massage options are plentiful, but none are particularly good. Trigger point therapy is probably partially useful, and all of the relevant trigger points are self-treatable to some extent, but probably cannot cure your ITBS. The value of deep transverse friction massage (popular among physiotherapists) is generally unproven and particularly in doubt for IT band syndrome, but does at least have actual curative potential in theory, and it is particularly easy to try. Deep longitudinal massage that tries to “elongate” the ITB (i.e. foam rolling the side of the thigh) is probably useless, but it might be somewhat useful if applied to the muscles that actually control the tension on the IT band.
- Strengthening the hips might be worth a shot based on a few shreds of inadequate scientific evidence in recent years, but it’s a long shot. On the other hand, who doesn’t want stronger hips?
- Stretching for iliotibial band syndrome is hopelessly mired in low-quality and discouraging evidence, and conventional stretches don’t even stretch anything and wouldn’t work even if stretching was a good idea. However, I provide suggestions for ITB stretching and mobilizing that might be more effective, and then explain why stretching and mobilizing the hip musculature as a way of self-treating trigger points may offer even better bang for your buck — although the overall value is still pretty unclear.
- Knee taping, strapping, and bracing are all worth a shot. I don’t believe there’s any hope of meaningfully changing the biomechanics of the knee this way, but there certainly is some hope of a useful neurological effect. In particular, it may be really helpful, for a while, to make the knee feel “safer.”
Before I dive into the treatment options, I’d like to respond to a common reader concern that I do too much “debunking,” and not enough telling you what works and exactly how to do it. Although I get few refund requests — way below industry averages — most of the requests I do get are caused by this specific concern: Doesn’t $20 get me a road map to a cure? A step-by-step action plan? The savvy exercise regimen that will make the pain stop?
These things just don’t exist, as I warned in the introduction. I have not sold you a book without mentioning that.
Even if they did exist, prescribing a treatment “plan” is simply out of the question, because every case really is different — that’s not just a platitude. What works for one person really is not going to work for the next. I promise that I’m not holding out on you. I am not a cure salesman, and I will not tell you what you want to hear. There is no specific method or series of logical steps that will reliably cure any kind of chronic pain problem, least of all the tough kind I write books about.
No plan survives contact with the enemy.
Helmuth von Moltke the Elder
Many people reading this probably think plenty of debunking is quite reasonable, normal, and even ethical. But imagine some of the unreasonable expectations I hear from a few customers. For instance, one woman asked me for a refund because my book offered her “only suggestions”! What else is there? What did she expect? Binding arbitration? Click this link for a cure? Free magic wand with every purchase?
Historical perspective and the Age of Hype
The disappointing truth is that there is only a motley assortment of rather underwhelming options with complex pros and cons, but usually more “cons.” Some are better than others, but quite a few are dodgy, for obvious reasons: hope sells, and so there are many more poor options than there should be. Please blame reality for this … not me.
And blame the people who have given you false hope and raised your expectations of musculoskeletal medicine far beyond what it can possibly deliver.
We are living in the “Information Age,” but sometimes it seems more like it’s the Age of Marketing and Hype. An almost unbelievable amount of the information we consume is generated to promote products and services. The result has been an unprecedented flood of being told what we want to hear about absolutely anything.
The reality is that musculoskeletal medicine is surprisingly primitive. Medicine has always had bigger, scarier fish to fry than treating mere aches and pains and injuries, which were barely studied at all until the 1980s. Musculoskeletal medicine is still a cocky teenager, just starting to come of age and figure out that it doesn’t know everything. Even sports medicine specifically, with so much potential funding and relevance to occupational injuries, has been bizarrely slow to build its evidence base.
The trouble with pseudo-quackery: treatments that seem way more legit than they are
The most prominent problem in musculoskeletal medicine today is the prevalence of what I call “pseudo-quackery”: treatments that are about as sketchy as any old-timey snake oil, but seem modern and scientific and mainstream. A few classic examples: laser therapy, ultrasound, platelet-rich plasma, prolotherapy, nerve and muscle stimulation. But there are many more.
These disguised quackeries are actually based mainly on surprisingly stale tradition, speculation, and authority. They generate more false hopes and wasted time, energy, money, and harm than more traditional quackery because they are vastly more popular and very much part of mainstream medicine, or very friendly with it — even many hardened skeptics aren’t expecting snake oil when they go to see a physical therapist or an orthopaedic surgeon.
So musculoskeletal medicine is a minefield, and a lot of debunking just goes with the territory. But it doesn’t mean there’s no good news at all.
The good news
Despite all the debunking and disappointing evidence, I do indeed have positive things to say about several of the options. I have started this part of the book with a summary of all the options, and I will conclude it with another summary of my recommendations, focusing on the positive as much as possible, and what to actually do. Many things are worth trying, even if they aren’t sure things or sitting on any solid science:
We’re told to strengthen this muscle or stretch that one, or inject this substance into an injury, or zap it with heat or electricity or ultrasound … and sometimes it really works, even though placebo-controlled trials fail to validate the treatment. I’m a big advocate of better science to really understand what causes injuries and how to treat them — but in practice, I also believe that sometimes it’s worth trying something, anything, just in case it successfully ‘reboots’ your injury.
Alex Hutchinson, Sweat Science
An encouraging perspective, but of course it doesn’t mean you should try any old nonsense. And you may save some time and money avoiding several others (or at least re-prioritizing them). You may even avoid the heartbreak of those that can do some harm. Knowing what not to do is half the battle, if not more! Understanding the topic well enough to prioritize the imperfect options is actually a huge win, the best you can realistically hope for.
The “negativity” of ratiocination is a surprisingly big topic, often funny, and sometimes profound. I answer the accusation in more detail in a compilation of tales of outrageous hate mail, the ethics and tactics of debunking, what it’s like to (supposedly) be the #1 Public Enemy of Massage (a therapy everyone loves to love), and — my favourite — “advanced negativity,” a discussion of how cynicism is baked into science in the form of the null hypothesis.
GO TO TOP • CONTENTS • NOTES
A placebo is relief from belief: people often feel better simply because they believe they have been treated. More precisely, it is the appearance or illusion of a treatment effect that is not actually attributable to a biological treatment mechanism. It’s a fascinating phenomenon, but its “power” is over-hyped.
This is a standard section in most of my books, covering several key points about placebo that are important context for any thorough discussion of evidence-based treatment options. I do not substantiate any of these points here — all the references are in a more detailed article about placebo.
- Placebo is not just one phenomenon — “the” placebo effect — but miscellaneous illusions that can collectively create the appearance of an effective treatment. Placebo is complicated!
- Placebo has a special relationship with pain. Reassurance (placebo) has more potential to relieve pain than most symptoms, because pain is strongly modulated by perception. But that only goes so far.
- Placebo is not a magical mind-over-pain superpower and its effects tend to be minor and/or brief. It can’t affect injury and organic pathology; it can only tinker with our experience of them.
- Placebo can also backfire. When a placebo effect wears off — as it usually does — people often fear that they must be really screwed, and then placebo turns to nocebo, placebo’s evil twin: feeling worse because of belief.
- Placebo potency is driven by whatever impresses the patient with the seriousness and legitimacy of treatment: risks, costs, size, intensity, technology and even odd minutiae like the colour of pills. This is why we have the concept of “therapy theatre” — because so much therapy is all about putting on a show.
- One of the best ways to impress people is with novel and intense sensations, because the patient can feel the “power” of the treatment. This is the basis of most manual (hands-on) therapies: they are sensation-enhanced placebos (“interactive therapy theatre”).
- Placebo has been hijacked and re-branded for its public relations value to alternative medicine. If your treatment isn’t evidence-based, no worries: you can still sell the power of placebo! “The power of placebo” is widely, weirdly used as a justification for therapy that can’t beat a placebo.
- Placebo does not work when you know it’s a placebo, contrary to what many people have heard (based on a couple bad scientific papers). The popular idea of “placebo without deception” is just bullshit, based on an experiment that created a strong expectation effect by inflating the participants’ expectations of placebo. So it was just an odd way of getting to the same phenomenon.
- Many snake oils supposedly work on animals, and if animals are immune to placebo then the treatment must be legit. But animals (and their biased human observers and caregivers) are definitely not immune to placebo. In fact, with animals there is even more opportunity for an illusion of a treatment effect.
We have a word for medical treatments that only work if you believe that they will, and it rhymes with “gazebo.”
Book Review, Unlearn Your Pain [Schubiner], by Scott Alexander
Is it okay to pay for a placebo?
Many people claim to be happy to pay for a placebo. As long as it works, who cares how? And placebo can work! So why not? This is an extremely common sentiment, raised in most discussions about a treatment that failed to beat a placebo in a fair test (invariably overlooking the fact that neither the treatment nor the placebo actually work very well).
I have no problem with people paying for a placebo as long as their eyes are wide open, but the wider your eyes get the less likely you are to get even a minor benefit.
And paying for things is never completely harmless.
Treatments with unknown efficacy but some plausibility and low risks are the least objectionable placebos to pay for. I’ve tried many such treatments, knowing full well that any effect I enjoy is probably just placebo (or regression to the mean, or natural recovery)… but it might be an actual effect, and I’m willing to pay a little for that chance. I’m gambling on getting a genuine benefit, with a bit of placebo as a consolation prize. So, for me, the plausibility has to be there.
Cartoon by Loren Fishman, HumoresqueCartoons.com.
What I want readers to take away from this is that placebo is not therapy. It’s mostly just an over-rated curve ball that accounts for an awful lot of temporary “success” stories.
GO TO TOP • CONTENTS • NOTES
Corticosteroids are potent anti-inflammatory agents (and not the same thing as the anabolic steroids taken by bodybuilders99).
Oral corticosteroids can be invaluable for management of severe widespread inflammatory conditions — like rheumatoid arthritis, say — but they are overkill for almost any painful “hot spot,” like trying to put out a frying-pan fire by turning on the sprinkler system. If you can avoid exposing other tissues to corticosteroids, you should, because they are a bit of a bull in a biological china shop.100 Injection is preferred for its precision.
But oral corticosteroids certainly kill pain! No doubt about that. The concern is about the side effects, which can be so dire that they should only be tolerated if they are the lesser evil, and only the most desperate patients should consider risking those side effects for IT band pain relief. Few doctors would sign off on it, not with injection as a perfectly good alternative. Injections are popular because oral steroids are a terrible idea for most musculoskeletal conditions.
The rest of this chapter will consider injections only — which have their own problems, but they are at least much more local problems.
People avoid needles and knives — we’re funny that way. It’s a sensible impulse, and it is reasonable to be reluctant to try the more invasive medical treatment options of injections and surgery. If you are squeamish about them — or if you simply wish to avoid the expense — then more conservative treatment methods are obviously worth a good try.
However, in the case of IT band syndrome, please do take these more invasive options seriously, particularly if the stakes are high for you, and basic therapy has shown no sign of working after several weeks. In the sections ahead, you’ll learn that ITBS surgery is attractive for a surgery — one of the best of all surgical options for any common repetitive strain injury. And steroid injections are worth considering much earlier in the healing process. In general, the invasive/medical treatments are more worth considering for ITBS than many other conditions.
Wherever pain is caused by inflammation, corticosteroid injections are also likely to produce substantial temporary pain relief — at the cost of a (minimally) invasive procedure with some risks. They can be injected with a needle, or blasted through the skin with an electrical charge (iontophoresis).
It’s limited, but there is half-decent evidence that injecting steroids into the side of the knee can help.101102 The evidence for short-term benefit is particularly decent in the case of tennis elbow (lateral epicondylitis),103 although there is also evidence that the long-term results are much less rosy, or even nasty.104 In some situations, steroid injections don’t seem to do well at all. The notorious rotator cuff of the shoulder is a hotbed of tendinopathy, and one of the most common targets of steroid injections. A 2017 review of 11 studies of 700 patients was scathingly negative.105
If ITBS isn’t acutely inflamed, why would a powerful anti-inflammatory medication be effective at all, even temporarily? Some possibilities:
- Maybe steroids don’t work as well as we are all in the habit of thinking (which seems increasingly likely as the years tick by and we see more reviews like Mohamadi et al). There might not be all that much a treatment effect to explain.
- And maybe cortisteroids are just helping for some other reason altogether — a happy biochemical accident — because steroids have many roles in physiology. For instance, steroids may have an effect on nerve pain, but not inflammation.
- Maybe RSIs cause more immune dys/function than it looks like. In this scenario, RSIs are not un-inflamed, just inflamed differently. And there is recent evidence suggesting exactly this in the context of garden variety tendinitis.
Steroids in a needle are generally much less risky than steroids in a pill: injection limits your exposure to one spot. But the main risk — and it’s not nothing — is that steroids actually eat connective tissue. Slowly. It’s not like strong acid! Nevertheless, this is a Very Bad Thing, and probably explains the data about long term harm …
It is clear that corticosteroid injection into tendon tissue leads to cell death and tendon atrophy. As tendinosis is not an inflammatory condition, the rationale for using corticosteroids needs reassessment, as corticosteroids inhibit collagen synthesis and decrease load to failure.106
Since the nature of repetitive strain injury is that tissue slowly “rots” and degenerates under stress, steroid corrosion of connective tissue is an ironic hazard — steroids may dangerously exacerbate the basic problem even as they relieve pain. The risk is obviously worst in the case of classic tendinitis, where structurally critical tissue may be weakened. Few people are keen to increase the risk of a rupture just for pain relief! That’s why physicians wisely limit steroid injections to about three (although that may be overly cautious, as we’ll see).
The danger is probably less with ITBS, however — if the injection goes under the IT band as it should, then it will certainly have less impact on the more structurally critical IT band proper, which is in turn an exceptional large, tough structure. It is not clear how functionally important the tissue under the IT band is, so it is equally unclear how dangerous it is to risk further degradation. Steroid degeneration of the contents of the lateral synovial recess may be almost completely harmless (best case scenario). Or, it could function somewhat like a bursal pad, and while damaging it won’t “blow” your knee, it could be similar to losing the protection of cartilage.
Unfortunately, many doctors are probably not yet aware of the recent evidence showing that it is tissue under the iliotibial band that actually needs the injection, and they will target the band itself — a shallow injection. The distribution of the drug around the point of injection is (hopefully) widespread enough that precise placement doesn’t really matter as far as pain relief goes,107 but we don’t really know, and injecting the IT band directly raises the concern that the steroids will unnecessarily degrade the IT band. It’s almost certainly better to aim under it.
The negative effect of steroids on connective tissue integrity is probably minor with limited dosing — a saving grace for this treatment. However, this is a most awkward and ironic collision of potential benefit with potential risk. There’s just too many variables and uncertainties here still, and no way to make a blanket recommendation for all patients: you have to weigh the pros and cons and decide for yourself whether you want to “go there.”
If three injections do not do the trick, you should probably stop trying, particularly if the pain relief is underwhelming. Some doctors refuse to do it at all because of the risk of harm, but most agree that one to three injections — particularly in this location, where the connective tissue is generally thick and tough — is no cause for concern. The danger is not great, and I suspect that, in the case of the side of the knee, up to twice as many injections are not a ridiculous idea, especially if they are widely spaced. However, there’s also no point in bothering unless they actually seem to make a significant difference: only consider more than three if you face a particularly unholy combination of great need and persistent problems (example108).
Final thought: if you’re going to try injections, be smart about it and use them tactically, coordinating them with other strategies and phases of rehab. For instance, be particularly diligent about resting in the immediate aftermath, so that you are hopefully combining the benefits of both and creating the best possible chance of success. And the corollary of that: don’t waste the injection by carelessly negating its effects with excessive use.
- Worst-case: no benefit, direct worsening of the problem (accelerated degeneration of connective tissue), and a poorer long term result.
- Best-case: significant short term pain relief without any significant adverse effects, and a useful aid in rehab.
GO TO TOP • CONTENTS • NOTES
Surgery is generally a poor approach to musculoskeletal problems — many popular orthopedic surgeries have been proven ineffective109 or even much more trouble than they are worth (like the metal-on-metal hip replacement debacle110). But not all surgeries are useless, and, happily, surgery for ITBS may be one of the exceptions to the rule.
The technique of the traditional open surgical approach — opening the skin to get at the IT band with a scalpel — is quite straightforward, although there are many minor variations on the theme. Basically, it involves loosening the IT band at the trouble site by cutting away a small piece of it on the side of the knee — a snip on the edge of the iliotibial band, like cutting a nick in the side of a wide elastic band. This doesn’t loosen the IT band overall, but it does loosen at the side of the knee, and presumably results in a significant reduction in the pressure of the IT band on the underlying irritated tissue — more than can be achieved by any other means (i.e. stretching). As discussed already, loosening the IT band in this way does not necesssarily imply that it was “too tight” to begin with — just that loosening it is a relief for the irritated tissue underneath it.
Again, as with the injections, the procedure is well-supported by the evidence:111112 it seems to work reasonably well for most patients, and complications are not a major concern.
The main downsides to the conventional open surgeries are:
- It fundamentally involves compromising the structural integrity of the IT band. Although this does not seem to present any major difficulty, doing so is generally avoided on principle, and this technique may seem barbaric in the future.
- Recovery takes several weeks, and you’re significantly off your game during that time. Because the IT band itself is cut, and this structure is under tension with every step (especially at this location), it needs plenty of time to heal before it is ready for active duty.
- The standard procedures, unlike the new arthroscopic option, do not provide any opportunity to diagnose and treat any other knee problem. If there is another problem at the knee, the standard surgery will not solve your problem.
As surgeries go, these are not serious disadvantages. For an intractable case of this type of IT band pain, you should not be too discouraged — this surgery helps most people.
But wait for the right moment! Considering surgery is fine, but it does bother me that some people lunge for the option before giving conservative therapy a fair shot. Most patients considering surgery have not yet adequately rested, even though 90% of them think they have. Once you understand what resting really means, it’s usually obvious that your attempts at resting have been inadequate … and then you have to decide whether you want to finally rest properly, or if it’s better to just get the surgery.
The problems with surgery and resting are different in substance, but similar in severity: both involve approximately the same amount of inconvenience. Neither is really an attractive option. Both can fail. Both can succeed. Which option you choose is almost a matter of taste. With surgery there’s a small but real risk of complications, and you know that your knee is going to be next to useless for two to three months afterwards, with greatly limited training for a while after that. To drive home that surgical results are unpredictable, here’s a surgery-gone-wrong story from reader Jill Fowler:
I had IT Band problems on and off for 2 years on both sides. I then had a surgery on the right knee to remove a small portion of the band, but things have not gone well. It’s been a year now. I had swelling that would come and go for months after surgery. For the first 9 months, I had to baby it by icing it after every run, bike ride, and during the day when I could. I also wore a closed neoprene knee brace to discourage swelling. If I ran on an uneven trail today, my knee would probably swell up.
She was told that a cyst was removed, so it’s possible that her case was unusual to begin with. However, finding and removing her cyst obviously did not do the trick (as it may have in other cases, described earlier).
With resting, there’s virtually no risk except to your time … but it’s also somewhat less likely to solve the problem, and it can take quite a long time of being very careful with your knee before you find out one way or the other. When it works, it’s fabulous — it’s always better to solve a knee problem without knives, if you can. But sometimes no amount of rest relieves the irritation under the IT band, and it can take months to really be sure one way or the other if it works.
GO TO TOP • CONTENTS • NOTES
As discussed above (starting in What’s actually irritated?), Michels et al and Hariri et al have demonstrated that it may be possible to treat iliotibial band syndrome not by loosening the IT band, but by removing irritated tissue in a pocket underneath it. Sounds great, right? Bring on the magic bullets! However, at least a little caution and patience is called for.
To recap, Michels et al, a group of Belgian surgeons, performed “resection of the lateral synovial recess”: they scraped out some thin, loose, irritated fatty tissue from around a little bursa-like pocket of tissue around the attachments of the IT band to the femur at the side of the knee, right down to the bone.113 The study was conducted primarily to test a principle, to try to prove exactly which tissues are the real source of pain. They did not cut the IT band. The results have been extremely promising. In an updated report in 2011, they reported 38 of 40 knees having “good” or “excellent” results — weighted towards the excellent114 — with all patients going back to sports within three months — and every single one of them started out with a serious, chronic case of ITBS. These results compare very favorably with the conventional surgery!
Similarly, Hariri et al experimented with bursectomy: they removed inflamed bursae or bursa-like tissues from immediately under the IT band. Like the Belgians, they got good results without actually cutting the IT band, although with far fewer patients: “Six patients were completely satisfied with the surgical outcome, 3 were mostly satisfied, 2 were somewhat satisfied, and none were dissatisfied.”
But the surgeons performed these procedures on only a small number of knees — 40 and 12. That’s not a lot of knees! Despite the promising results, these techniques have not yet been established as effective or safe, and they certainly must still be thought of as experimental. It is possible, for instance, that the effect was a placebo. That may seem unlikely — and it probably is unlikely — but a placebo is often a surprisingly powerful thing, and several prominent scientific studies have shown that sham knee surgeries can fool people into “healing”!115
Despite these concerns, another reason to at least consider discussing this surgery with your surgeon is that it is an arthroscopic procedure — inserting a tiny camera through a tiny incision — so it is minimally invasive, plus the surgeon can easily see and correct other minor knee problems at the same time. In the 35 knees described in their 2009 report, Michels et al also found one case of femoral cartilage damage, two mensical tears, and a lateral recess with some “gravel” in it — a “calciﬁed loose body.” That last example is quite a fascinating finding and yet another interesting, unconventional explanation for the existence of IT band syndrome in the first place, and why nonsurgical techniques might fail. That person literally had something bumpy stuck under the IT band! Remember the “rock in shoe” analogy? It might be an especially good description of some cases! These other problems were corrected, which is a major advantage to the procedure.
Best of all, though, it’s less destructive and recovery is much quicker than snipping the IT band. Faster recovery is a major benefit, particularly for an athlete.
A reader talks to three surgeons
Reader Conor G., and ITBS sufferer for several years, visited three surgeons in 2021, and their views represented the full range of views on surgery for ITBS. I thought it would be useful to share this real-world experience with asking surgeons about these procedures for a very stubborn case. Conor writes:
- One surgeon (apparently one of the best in the country here in the UK) was cavalier and said outright that they’d stick with the “newer-older” methodology involving a small 2cm incision into the side of the knee, which is apparently day surgery.
- Another fancy surgeon in London looked over the Michels paper and thanked me for directing his attention to it, and seemed to have an open mind about the approach. Ultimately, he was cautious and argued the case for the better-known methods, and that’s as far as we spoke.
- The final surgeon, who is the one I have mainly been working with to understand my particular case, is very cautious about proposing any surgery for ITBS. He flat out told me that he would never personally opt for surgery in that area of the knee himself, and so he’d urge his patients not to either. He’s sympathetic to why someone might want surgery, but he thinks that one small mistake in that area of the knee could easily make things worse, in terms of scar tissue build up, or even risk someone’s leg if they went to develop lateral compartment syndrome. As he put it, “we might not be able to make you better, but we can definitely make you worse.”
I thought the latter case was particularly interesting and might be important to highlight to readers that not all surgeons think there’s enough evidence to support knifing into the side of the knee.
GO TO TOP • CONTENTS • NOTES
Most drugs work on only about a third of the population, they do no damage to another third, and the final third can have negative consequences.
Craig Venter, extremely famous and spooky smart geneticist (public lecture, Vancouver, May 3, 2011)
Vitamin “I” — ibuprofen, the main ingredient in drugs like Advil and Motrin — is an almost universal treatment choice for iliotibial band syndrome (and, of course, every other repetitive strain injury). The drugs ease inflammation and fever, and the injury seems to be inflamed, so it’s a perfect match! Or people just take them because it’s a pain-killer and they have pain to kill. For one reason or another, nearly every patient and professional assumes that NSAIDs are at least somewhat helpful, though few are foolish enough to think it’s any kind of a cure.
In fact, the NSAIDS are probably one of the weakest treatment options — because of course repetitive strain injuries are not actually very “inflamed,” per se.
Scientific evidence on this topic has always been scarce and discouraging,116 and even the anecdotal evidence for ibuprofen is weak. I’m sure there are some testimonials for ibuprofen — there are testimonials for anything. But consider: even though ibuprofen is probably the first or second line of defense for virtually every case, the world is clearly still full of serious, chronic iliotibial band syndrome … that ibuprofen could not stop.
(Many athletes, especially runners, swear by ibuprofen as a prophylactic to prevent soreness during competition, but that’s quite a different usage, and it definitely doesn’t work.117)
So, NSAID chemistry is laughably irrelevant to the chemistry of IT band pain,118 but it gets worse: they may actually interfere with recovery from the connective tissue degeneration that actually is the problem, because NSAIDs may actually retard soft-tissue healing119 (and hard-tissue healing too, for the record120) Just what every RSI victim needs! (Fortunately, they don’t actually damage connective tissue, like steroid injections. Probably.) There’s no direct evidence that NSAID use will impede recovery from IT band pain, but it’s possible.
And it gets even worse! NSAIDs are also well-known as “gut burners” for their disagreeable and common effects on the gastrointestinal tract, which is a deal-breaker for many patients. And they can, paradoxically, actually cause headaches.121 Oh, and one more thing: they increase the risk of strokes and heart attacks, even in healthy people, at any dose. (Diclofenac [Wikipedia], a popular oral NSAID almost everywhere on Earth but North America, has even worse cardiovascular side effects than the others.122 Oral diclofenac specifically should probably be banned.) Lovely!
A drug is a poison with potentially beneficial side effects.
Dale Favier, Massage Therapist, poet
I know some readers are thinking right now, “Yeah, well, okay … but I’m still going to take my Vitamin I.” With dosing caution — small doses, short-term use — I have no serious objection. If there’s any reason to take them, it’s that they might relieve some pain by unknown mechanisms (the inflammation question is not exactly simple).
Or — and this seems almost crazy, I know — you could just actually heed the science, ignore the conventional “wisdom,” and never bother popping another NSAID unless you’ve got some uncomfortable classic inflammation to take an edge off. Imagine two NSAID scenarios …
- The (not-unlikely) worst case scenario: slowed healing, aggravated pain, GI tract upset, increased chance of a stroke or heart attack, headaches, waste of valuable seconds popping pills.
- Best-case scenario: temporary modest pain relief, no side effects.
Speaking of dosing caution …
Voltaren is basically another NSAID (diclofenac) in a tube, and a relative newcomer to the range of options. Because you smear it on and it’s absorbed through the skin, you don’t have to carpet bomb your entire digestive tract and circulatory system with the stuff to get it to the problem. This significantly reduces your overall exposure to the risk of side effects123 — which is important, because the same stuff (diclofenac) taken by mouth has some serious problems124 — but you still get an adequate dose into the tissue with the issue.
Another reason that Voltaren is interesting and well worth bringing up here: it would never have been approved for sale if it didn’t have some genuinely persuasive evidence attached to it. The stuff actually seems to do something for arthritis pain — pain that probably has much more in common biologically with RSIs. So we’ve got something like a shred of a reason for optimism here and greatly reduced risk. Yahtzee!
- Worst-case: It could be just as much of a chemical clean miss as any other medication, in which case you’re basically just smearing expensive Vaseline on yourself.
- Best-case: It could actually provide some real pain relief, with a very low risk of side effects.
To wrap this up, here’s comedian Louis CK satirizing a doctor talking about the painkiller dilemma: “Oh, it’ll do some intestinal damage after a while. But you’ve just got to weigh that against how much you like your ankle not hurting!” This is a short excerpt from his 2008 stand-up show, Chewed Up.
GO TO TOP • CONTENTS • NOTES
The apparent value of icing for seemingly “hot” and allegedly inflamed pain like IT band pain is mostly the poetic, non-medical mental imagery of cooling. The problem is not heat, of course, and it can’t be fixed by cooling.
That said, I once went down a mountain with acute IT band syndrome, and I may not have made it without ice (or snow, in that case). It may have “only” been a case of timely and extremely short-term pain control from numbing … but that counts when you’re trying to get off a mountain safely.
If ice can help a repetitive strain injury in any way beyond brief numbing, no one has ever actually proven it or shown how it might work125 — an ordinary, common home remedy that science has almost totally ignored. There’s little doubt that it’s relieving in the short term, and maybe it stimulates miscellaneous minor tissue healing processes as well. Virtually any stimulatory input to the body, up to a point, can provoke a healthy response, because of the use-it-or-lose-it principle. Stress a tissue, and it will probably get tougher (adapt) in some way. That’s the only plausible therapeutic mechanism of icing. Ice may simply be one of the easiest delivery systems for a bit of stimulation — a way to stimulate tissue without overloading it, while simultaneously getting some temporary pain relief from numbing.
It almost certainly isn’t “anti-inflammatory” in any meaningful sense for IT band syndrome.
The great advantage of ice as a treatment is not its impressive biological effects, but its thrift, ease, and safety: treatment options simply don’t get any more innocuous while still having some plausible mechanism of benefit. Therefore ice remains firmly on my “worth a shot” list for RSIs. Keep your expectations low, but there are virtually no risks, other than ice burn (which takes at least a couple minutes — probably even twice that — of raw ice application).
Used properly and safely — with a little caution not to “burn” yourself — there’s really no limit to how much icing you can do, and more of this good thing might be better. If ice works at all, particularly via the stimulation of tissue healing, then the benefits could be cumulative — even if the effect is minor.
Power icing. For these reasons, I have experimented with recommending a lot of icing for IT band pain — many times per day, as much as thirty brief doses (a minute or two) of raw ice, way more than the recommendation you would receive from most health care professionals — and some of them have seemed to enjoy excellent results. That is a nearly useless statement — it’s far too small a group to draw any serious conclusions about this approach — but the concept makes some sense and has virtually no downside. Try power icing for a few days, and see what happens.
Ice gel packs are not the best choice; instead, use “raw” ice, bare ice, ice-to-skin contact. An ice cube held in a dish towel will do in a pinch, but use an ice cup if you intend to spend any real time at it: fill a styrofoam cup with water, freeze it, cut the top inch off, and you have a large ice cube with an insulated handle. (Handy commercial ice cup products are now available as well.) Apply ice in slow circles to irritated tissues for about two minutes maximum, or until you’re numb, whichever comes first. You can do this as often as you like, as long your tissues have a chance to warm up between applications.
Note that icing is going to be effective only where the problem tissue is superficial — which it is, in the case of IT band pain. Please see Icing for Injuries, Tendinitis, and Inflammation for more detailed information.
Precision icing timing
It is possible/plausible that timing could be important, and again this is a refinement that can be implemented with basically no risk: if it’s worth trying to ice your knee, it’s worth trying to do it at times that make sense. Try icing when your knee hurts — or when you suspect that it might start to hurt but before it actually does. In other words, “head it off at the pass.” As pure pain control, of course it makes sense to apply ice at the time you need to control pain. For runners, this could be a way of adding time to your run more aggressively with minimal risk. But there might also be some tissue benefit to icing at the times when the strain is greatest, or immediately after a walk, hike, or run.
Extra tip for hikers: if you are struggling with iliotibial band syndrome on your way down a mountain — a common scenario — do not hesitate to pour icy stream water over your knee every chance you get! Very helpful — and icy stream water is more common than snow.
Don’t worry about aggravating trigger points. Astute readers will note that, elsewhere on the website, I warn that ice has the potential to make trigger points worse. Don’t worry much about that in this context.126
GO TO TOP • CONTENTS • NOTES
If it’s worth icing, it’s worth contrasting. Ice packs and heating pads are familiar rehabilitation tools, but many people have never heard of therapeutic contrasting: quickly changing tissue temperature from hot to cold and back again. This is usually achieved with hot and cold water, either dunking a limb or even immersing the whole body.
Contrasting is a tremendously good, simple idea, and I promise that it feels better than it sounds when it’s done right. The point is to force your tissues to adapt to the sudden changes, which are stimulatory and require a lot of metabolic activity and circulatory gymnastics. Basically, contrasting constitutes an extremely gentle tissue workout: stimulation without stress and strong sensations without movement, which may be quite helpful for a body part that badly needs some rest while it heals.
Such as a knee with IT band pain.
What does the science say? Not much about this, unfortunately — just a handful of studies, all about using contrast to accelerate recovery from exercise, and notable for failing to turn up anything promising .127 Contrasting for recovery from injury is definitely unproven too, but also more reasonable and plausible, costs nothing, and is almost perfectly risk-free.
Contrasting knees is a bit mechanically awkward: they are just not anatomically convenient to heat up and cool down. (Hands and feet are much more convenient for dunking.) Your Mission: Difficult, should you choose to accept it, is to thoroughly heat the knee up for about two minutes, then cool it rapidly for about one minute. Do that three to six times. Use enough heat so that the cold feels refreshing, not alarming, and finish with cold.
- about 2 minutes of heating: comfortably hot
- about 1 minute of cooling: cool, not cold (unless you’re tough)
- about 2 minutes of heating: hotter!
- about 1 minute of cooling: colder!
- about 2 minutes of heating: hot as you can handle
- about 1 minute of cooling: cold as you can handle
But how? There are several options, none of which are ideal:
- Pouring. The easiest method, but probably not the best, is to simply sit on the edge of the tub in your shorts and repeatedly fill a medium sized-container with water and pour it over your knee.
- Big bucket immersion. The premium method would be full immersion in extremely deep buckets — if you have them, and if you’re short enough to submerge your entire calves and knees. However, the right buckets may be hard to come by, and would take quite a while to fill.
- Detachable shower head. Just get into the shower and start sprayin’. This is so much more convenient than other methods that I recommend actually going out and buying a shower head for this purpose, which is probably the maximum possible expense for this self-treatment method (and of course it’s also useful for actual showering). However, the effect of spraying is not as good as immersion, and a low-flow model may not cut it. An advantage to the detachable shower head is that you can easily include the entire leg, thigh, and hip, on the off-chance that stimulating the whole region is more useful than just the knee. However, beware of spreading your spray too thin and inadequately contrasting the knee itself.
- Wrapping in sopping wet towels. Get yourself a pair of medium sized buckets of hot and cold water and four good absorbent hand towels. Put a couple towels in each bucket, and put everything in the tub. Wrap a hot wet towel around your knee, then a cold one, then a hot one. This is fussy to set up, but it works quite well.
Contrasting the calf at the same time as the knee is a good idea, if you can do it. For example, immersing the legs in smaller buckets is more convenient, and you can sit with your legs in buckets while also pouring water over your knees. The more tissue south of the knee that you can heat, the better: it will force greater changes in circulation that have to go through the knee.
Be creative! And be safe. The sole hazard of knee contrasting is a low, low risk of burning, if you are particularly careless and self-abusive — so don’t burn yourself! For more detailed information and many more tips and ideas, see:
GO TO TOP • CONTENTS • NOTES
This is not about ITBS treatment per se, even though it concerns an all-too-real email from a real person with real knee pain. He was an extremely dissatisfied customer, and basically his problem was the “negativity” of the treatment reviews. However, he spells out an unusually self-destructive attitude that I can usually only see between the lines.
This desperate knee pain patient actually says point blank that he wants me to lie to him, to tell him what he wants to hear, to give him a miracle cure that does not exist …and, if I would only supply that, he told me: “I have a lot of money for you.”
But he clearly does not want education, nuance, or any discouraging forays into fact. Here’s the highlights of the email (reproducing all errors), with some of my snarky fantasy responses (my actual responses were kinder and gentler):
Can’t do my job anymore as an electrician. Can’t stand without the sensation of a hot iron on outside of knee along with weakness and shaking. I’ve seen four physio therapists. Shockwave therapy. Laser therapy. Acupuncture with deep muscle stimulation (pulsed DC).
“Well, there’s your problem.” That’s three particularly terrible treatment methods in a row. I’ve linked to critical analysis of each. And as for “four physiotherapists,” it really depends on who you get: it can go well, but there’s still a lot of pseudo-quackery in that profession.
Over 120 minutes a day of exercises which you say are useless.
I do not say that exercise is “useless.” I don’t secretly believe it. I don’t even imply it. If that’s what you’re getting from my book, you’re reading it wrong. Unless you’re trying to fix IT band syndrome by stretching for 120 minutes per day, I don’t think your attempts to exercise are “useless.”
Please stop writing pages upon pages of how everything I and my physiotherapists, naturopaths, doctors, etc are doing is wrong. I don’t want to read a book explaining opinions and your experience and the research you went through.
I want a protocol. Tell me what to do to fix this. I am happy to put in the work. I am happy to pay money. But your literature seems to be a dissertation on why the typical things don’t work. I don’t care.
You should care! You could save yourself a lot of time and money.
Write a panflet [sic] called “how to get out of debilitating chronic pain from it band syndrome by following this protocol guaranteed” and I have a lot of money for you.
That would be fraud, because there is no such thing.
Wish I could buy more of yiur [sic] stuff because I am desperate. But you are failing yourself and those of us in pain with what you are presenting.
Mister, the only thing I’ve failed to do is bullshit you. If you really want to pay someone to just tell you what you want to hear, you won’t have any trouble finding someone to do that for you. But you can’t buy that here.
GO TO TOP • CONTENTS • NOTES
It’s hard to stop using your knees: this is basically why iliotibial band syndrome is hard to treat. Most of the common overuse injuries afflict anatomy that we rely on heavily, of course. But you’re going to have to try!
The basic template for all injury rehab is to “calm shit down” and then “build shit up.”128 Resting properly is about taking that calm-shit-down phase more seriously than most people do, and then working your way back up to normal physical stresses more cautiously than most people do. When I talk about “resting,” this is what I mean: much more than just taking it easy for a while, but a logistically challenging process of eliminating knee stresses and then gradually re-introducing them.
It’s all trickier and more important than most people realize. It is often underestimated or simply ignored as a factor in healing, yet it is the most important part of therapy for any repetitive strain injury — perhaps more important than all other treatment options combined. It is usually what people who think they’ve tried everything have not actually tried — not well enough.
Resting will not work for everyone, but it’s very important to make the effort. A rest-test should be your “plan A.”
Obviously, if you don’t exercise at all, it is not good for you. Exercise improves your health. And a lot of exercise improves your health a lot. But that doesn’t mean that insanely large amounts of exercise are insanely good for your body. At some point, too much begins to damage various physiological systems. Everything in physiology follows the rule that too much can be as bad as too little. There are optimal points of allostatic balance.
Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 123
Runners are their own worst enemies
Runners often think that iliotibial band syndrome is stubborn. It is, of course, but runners are probably even more stubborn! The runners most likely to get injured in the first place — serious long-distance runners — are the same runners most likely to keep running through the pain or never rest enough to make a difference. They don’t take the injury seriously enough.
ITBS may be a relatively minor injury, but it is an injury, and it will probably not just magically go away if you keep pissing it off.
The importance of rest: the cheek-biting analogy
When you bite the inside of your cheek, the tissue is damaged and becomes inflamed: hot, red, and swollen. The swelling, of course, makes it exasperatingly easy to bite it again … and again, and again. The physiology of cheek bites is different, but it’s a lot like a repetitive strain injury in its sensitivity to reinjury and the resting required to recover.
Ask yourself: if you were trying to recover from biting the inside of your cheek, would any amount of cheek-biting be acceptable? Absolutely not. And it’s the same with this. Keep this useful image in mind as you go through recovery. Don’t keep “biting your cheek”!
How does resting fail?
Most people reading these words have already tried either “taking it easy for a while” or more of a break from the most aggravating activities (running) for a longer period. It’s common for me to hear from runners who have stopped running or reduced their training volume for long periods, only to have the pain come roaring back when they try to ramp up again. Some cases are immune to rest, but in many cases the resting simply wasn’t done well enough. There are several ways these seemingly earnest, worthwhile resting efforts can be inadequate for the tough cases:
- “A while” just wasn’t long enough. (People often say “a while” when what they really mean is “I took a week off.” A week is not enough.)
- It also usually isn’t enough to just “take it easy.” (Ironically, in the case of running, taking it easy often means a slower pace … which might actually make ITBS worse, as discussed earlier.)
- Even if running is dropped completely, many other activities can easily continue to generate low-grade knee stress — not necessarily enough to be obviously uncomfortable, but enough that you’re not really “resting,” enough to prevent or slow down recovery.
- The rest may not have been well-supported and coordinated with other treatment efforts. Rest alone is not enough in most cases. In addition to removing stressors, you also need to do what you can to support recovery.
- Ending rest too abruptly. Like a lot of medications, you can’t just suddenly stop resting and go back to normal activity. It’s important to baby-step your way back to normal knee stresses. That tedious progression is the soul of rehab.
So how much rest exactly?
Some stubborn cases might yield to as little as a couple weeks of really good quality resting. Most will take at least twice that. The worst cases could take three to six months — mine did — though you should never invest that much time in a serious resting without some obvious progress129 (or if it’s not that big a deal to you130).
- For a mild new case, three days of good rest, followed by a couple weeks of taking it easy, could be enough to resolve it.
- For the average case, you probably need about one week of good rest, followed by a couple months of gradually getting back to normal.
- For more severe and entrenched cases, a month of near total knee rest might be required, and it could take a full year of cautiously training the knee to tolerate athletic stresses again. Runners are often horrified when I tell them that the “rest” period is just the beginning, and they may have to go back to running like a beginner — but that’s how it goes when you’re injured.
There’s no way to know in advance how long your case might take … and it can be hard to tell if it’s working without testing it out and going for a walk or run — which could re-irritate the problem just as you’re finally making headway. There are two basic strategies for dealing with that dilemma, and which you choose is a matter of personal style.
- The overkill method — get it all over with a single mighty resting effort, possibly much more (and more inconvenient) than you actually need. But it will either work … or you can scratch it off the list and honestly claim to have really tried the heck out of resting.
- The escalation method — make the minimum investment in resting that might work. If it doesn’t work, you up the ante and try again. If you’re lucky, your first or second attempt will do the trick. If you’re unlucky, you’ll try longer, deeper phases of resting several times in a row — a long process — and still fail. (I was an escalator with my own ITBS.131)
Total rest? Should I use a wheelchair, or what? Crutches, maybe? Just how much should I avoid knee stress?
Truly total rest/immobilization is rarely a good idea for any kind of rehab; we even avoid casting fractures these days, whenever possible. However, for anyone who can swing it logistically, it can be a good idea to temporarily go to extraordinary measures to reduce knee stress. To “calm shit down” more aggressively than you probably ever imagine when you started this book.
A wheelchair is a big step, a complicated thing to adapt to. I wouldn’t recommend it for any case except the most extreme.
Crutches, similarly, are probably overkill for most cases. They also have their own risks — they are extremely awkward. However, they are quite accessible, and you might consider using them part-time for a few days.
Canes and walking sticks, however, are truly excellent options: easy, effective, and practical. They significantly reduce knee stresses without cramping your style too much. It’s a really good idea to integrate one of these into your resting plan.
Is it possible to heal without resting?
Probably not, no — at least some rest is required. I am not aware of any case of iliotibial band syndrome actually resolving while someone was still running and progressing with training. I’m not saying it’s impossible, but it must be difficult and rare. Someone out there with a mild-to-moderate case of iliotibial band syndrome might manage to heal without really slowing down. But that person is probably not you.
I have occasionally seen cases resolve while running at a significantly reduced intensity. If you diligently take care of your iliotibial band syndrome in every other way, and if you slowly increase your running over a month or two, you might recover from iliotibial band syndrome while still running. But that’s a riskier road to take.
And yet rest alone may not be enough to make ITBS go away. There’s no way to know for sure, but who seems more likely to recover: the person who just rests, or the one who rests and uses every other rational treatment option available at the same time?
Is there any science about how well resting works, or the best way to do it?
Not really, no. We have no evidence-based guidance on how much resting is effective, or exactly what tactics work best. The importance of resting seems to be too obvious for science to bother testing directly.
We really know nothing about exercise dosage for any kind of chronic pain, and exercise dosage is just a mirror image of resting dosage: less exercise is the same as more resting.132
One of the main conclusions of a major review of “How much is too much?” is that there’s not enough research, and what we do know is mostly from limited data about a few specific sports.133
I really wish someone would do a nice controlled test comparing “extreme” resting for runner’s knee (avoiding most knee stress from any source) to ordinary resting (avoiding obvious sources of knee stress from running or workouts, but otherwise carrying on as normal).
But that’s a pipe dream. I doubt I will see it in my lifetime.
There are scraps of relevant research here and there, but mostly we have to read between the lines of research on the risks of excessive loading in sport. If too much loading, too fast, is the major risk factor for injury, that strongly suggests that less and slower loading — “resting” — is probably effective injury prevention… and what prevents ITBS often also treats it. So I am not exactly going too far out on a science limb recommending good rest.
Bottom line: my resting advice is based on scientific plausibility, relatively low-cost, and virtually no harm. But not, unfortunately, not a stitch of directly applicable research — not even close.
For (quite a lot) more about how and why you should rest, see The Art of Rest.
GO TO TOP • CONTENTS • NOTES
A major part of the art of resting is finding ways to stay active and fit without placing stress on injured or severely fatigued tissues. Like rest in general, relative rest is a neglected concept in rehabilitation. The challenge can and should be tackled with precision and creativity.
For many athletes, the prospect of resting for weeks while recovering from ITBS seems like a shocking training setback. One of my readers emphatically told me that she would lose her edge in a matter of days if she couldn’t keep training, throwing off months of carefully timed preparation for the next marathon.
This fear of resting is a very common, nervous objection to resting: the fear that you will “go to pot” or get critically out of shape. It’s true, you can lose your athletic edge pretty quickly. Optimal, competitive fitness takes hard, constant maintenance. But you lost your shot at maintaining optimal fitness the moment your knee started hurting … and you aren’t going to get it back until it stops. And your next marathon was a lost cause the moment your knee started to hurt, so blowing the training schedule is pretty much a moot point.
The only thing worse for an athlete than having to take a break is failing to heal entirely.
For highly motivated individuals, it is often emotionally vital — sanity preserving, even — to find a way to continue training anyway (and there is always the marathon after the next one). So we look for alternative forms of exercise, ways of training without pissing off the bad knee.
If you rest, you certainly won’t “go to pot” in a month. Or two. Or even six. But you certainly will go to pot if you never heal! Long-term pain is a much greater threat to your fitness than short-term resting. And nothing will keep an overuse injury going like more use! So, first things first. It takes what it takes. In general, you must be healed before you can maintain or develop fitness, let alone optimize it.
One simple way to stay in shape while protecting your knee is to switch to cycling or swimming … unless you’re already a cyclist or a swimmer, in which case you have to come up with something even less stressful.
Swimming is intensely aerobic and relatively “knee neutral.” You can improve the knee protection substantially by using a pull buoy.137 Unfortunately, swimming is not a practical or desirable option for many athletes. Not everyone’s a swimmer. Cycling is a more popular backup exercise.
Cycling. So for a long time, I particularly recommended cycling as an alternative form of exercise to runners who were recovering from iliotibial band syndrome. On the one hand, cycling is probably not as hard on ITBS as running, because “the foot-pedal forces during cycling are only 18% of those occurring during running while the ITB is in the impingement zone.”138 But, yikes, do you really want to be irritating your iliotibial band syndrome 18% as much as usual?
For some athletes, the answer is yes: an 82% reduction in irritation of the knee — while still being able to train aerobically — is an absolutely acceptable risk. For a triathlete, shifting the focus of training to the bike is actually productive instead of a frustrating distraction. But for a pure marathoner who has no particular interest in cycling, enjoys swimming, and lives near a pool, it would make much more sense to switch to swimming rather than risk the irritation of cycling.
How about elliptical machines? Probably okay for most people, but it depends, and they have one obvious disadvantage compared to cycling: less control over loading. On an elliptical machine, you’re always bearing your fully body weight. On a bike, you can dial the resistance down much lower. And yet they have their place. They are clearly not as hard on the knee as running for most people.
GO TO TOP • CONTENTS • NOTES
Judy Baloo is a Toronto native formerly from my own home of Vancouver. She has been running for about 15 years. Her first half marathon was in 2011, on her 40th birthday, and in 2016 she decided to commit to training for a marathon. Her first was in 2017 in Ottawa, followed by the Scotiabank Waterfront in Toronto in September 2017, and then Boston Marathon in April 2018. She was looking forward to a summer of training for the New York marathon that fall.
Things were looking great. But that was an awful lot of mileage, without any injuries, so maybe it’s not surprising that her number came up.
Phase One: Judy realizes she’s got a problem
On June 17, about 7 kilometres in to a run, she noticed some strange discomfort — “not really pain, just odd” — on the outside of her left knee. This is an example of a slow onset; many runners are in agony within minutes.
The next day, while out for an easier, slower run with a friend, it came back again, and this time there was some pain, but it was still trivial. She knew enough to suspect that it was IT band related, but it didn’t seem bad enough to abort the run. After that, though, she took a few days off and did all the conventional stretching and icing, taking the advice that you can get from 10,000 articles and videos.
But she didn’t take a real break. She was back to training soon, and right into a longer run. The pain started around 12 kilometres.
That’s where I should have stopped! But I decided to run the last part of my husband’s run with him. He is a slower runner, and it was during those couple of slow kilometres that my knee became really painful and there was no denying that full-blown ITBS had arrived. As the day progressed even walking became painful.
Notice that twice now in this story her symptoms have flared during slower running. Just sayin’.
Phase Two: Things get more serious
For three months she battled the pain: massage, acupuncture, ice, stretching, and more. Everything except solid rest, of course. Initially she switched to cycling and it was a week before she realized that cycling was actually contributing to the problem. She began a run/walk regime, and soon found that 5 minutes of running were too much and so she eventually settled on 3:1.
Things looked up for a while. She found that running at a faster pace didn’t set off nearly the discomfort of running at a slower pace. Things were starting to feel less bad, and she was starting to get optimistic. Relatively minor flare-ups could be tamed with ice. But in retrospect, she was simply avoiding most of the problem with a less demanding training regimen. And
That should have been the clue to take New York off the schedule. But nope! As you say in your tutorial, I was ready to do anything to keep running — except stop running.
That’s when she discovered this tutorial, which she claims to have devoured in a single sitting, seeing herself reflected in the words again and again, nodding furiously at almost everything. “It all made such sense! Except, of course, the part about resting. I just flat out ignored that part, because I didn’t like it. Real Runners Keep Running!”
And there were only 7 weeks left to ramp up to the marathon distance.
Phase Three: Acceptance
But the next time she ran, it was bad, and the light finally went on as she ran. “I couldn’t hide from it for long. I couldn’t seriously believe, after everything I’d been through, that it was was wise to impair the healing process even further by pouring on the intensity until a marathon that fall.” It took her the rest of that run to come to terms with it, but she did.
She withdrew from New York — always a tough choice for any marathoner. And she gave her knee a thorough resting, and then resumed training very cautiously. “Probably not as cautiously as I should have,” she says, “but a lot more cautiously than before. Baby steps!”
And then she ran the Boston Marathon the next year. And a few more since then.
Rest is never guaranteed to work, and anecdotes aren’t evidence of efficacy, but this is a nice story of apparently successful load management. It seems like Judy was a runner who just had to come to terms with not running for a little while — and then she could get back to it without much difficulty. Sometimes it’s that “easy.” Though even with a clear cut success story like this, which went just about as well as any determined runner could dare to hope for, it wasn’t actually easy or quick at all, and it cost her a marathon and lots of frustration and uncertainty.
GO TO TOP • CONTENTS • NOTES
Over the years, a handful of readers have reported a simple way to achieve short-term relief from ITBS: the duck-footed posture, turning your feet outwards while you walk (or just the affected side), also known as slue-footed (the odd official term). In the midst of an acute flare-up, people have claimed, this significantly reduces the severity of the pain.
This is not a difficult or risky thing to experiment with, and it’s well within almost everyone’s movement repertoire. Pointing the toes outward comes almost entirely from external rotation of the hip, and the hip can certainly handle it.
The minor cost of this gait is that it’s a bit inefficient. (Please ignore the zillions of articles online that go way overboard and demonize this alleged movement “defect.” It’s not biomechanically important unless it’s quite extreme.) We normally keep our feet aimed in the direction we’re going because we use our toes in walking and running. If you try to run with highly exaggerated external rotation, you’ll quickly discover that it’s not something you want to do for all that long.
But it might be handy in a pinch. If it reduces the pain. If it works, it has three main interesting implications:
- It suggests something about the nature of the beast, though I am not sure what. My first guess would be that it reduces tension on the IT band, primarily by the mechanism of making it harder for the gluteal max to pull on the IT band — because it is both a major external rotator of the hip and partially responsible for IT band tension.
- It might be a way to help you get home if you get stuck with strong ITBS pain. If you get into trouble on a run, and you can’t get a ride home, you might be able to duck-foot it home more comfortably — and limit the severity of the flare up.
- It might be an effective tactic you could use to assist with load management throughout rehab. If it’s a way to walk with less irritation, by all means, every time you have to walk (or descend hills/stairs) during rehab… maybe a little external rotation to reduce its impact.
Some ducking doubts
It seems a little bit unlikely to me that this will relieve pain in the majority of sufferers, simply because it doesn’t seem like a hard solution to stumble on. Surely more people would know about it?
I did not stumble on it during my own severe bout of ITBS in the late 90s. And — importantly — I already swing my right foot way out to the side. I have a slightly gimpy foot. Specifically, I have a “fixed forefoot varus,” meaning that the front of the foot is twisted away from the midline, just because the bones are shaped like that.
My foot does not look deformed at all, but it does have an effect on my foot position and gait. It’s minor and subtle, but unambiguous. As soon as I could walk, I did so with my right foot turned out. The first time my parents took me cross-country skiing, when I was just a tiny lad about three years old, I had trouble keeping my right ski in the track! It just kept popping out. I tell the story of my funky foot in more detail in my plantar fasciitis tutorial, where it’s most relevant.
For our purposes here, suffice to say that my chronically ducky foot position obviously did not protect me from ITBS. Not only that, I had always assumed that it was probably part of the reason I was vulnerable to ITBS in the first place! Not that I actually know, but it always seemed like a reasonable hypothesis.
Maybe slue-footed posture is only helpful for ITBS when the external rotation is particularly extreme. And maybe that explains why most people don’t stumble on it. But, if “particularly extreme” is what it takes, it’s also proportionately less useful as a load management tactic.
And maybe it only works if the external rotation is relative to your normal posture — which is why my normal duck-footing was irrelevant. Perhaps I would have noticed an effect if I’d made a point of swinging my foot further out.
Try it and let me know!
Having added this chapter to the book, I hope I can collect some reports from readers. At least half the people who buy this book are patients with serious ITBS cases. If that’s you, please try this, contact me, and report your experience. With any luck, I can update this chapter with better anecdata. 😜
Here’s the only example I’ve received so far (the absence of reports being noteworthy in itself). From reader Eugene Zolenko (attributed with permission, of course):
Just read about duck-footing relieving ITBS and want to add my own case — it totally does. I got my ITBS after a 14-hour hike going up and down two peaks in the same day and then descending in a dry creek bed with lots of boulders. Up a boulder, down a boulder, up and down!
Anyway, since then I often get flare-ups when going down a mountain (or a long walk with a kid on my back). Rotating the foot outwards helps when going down a reasonably steep slope, as well as not bending the knee when possible.
GO TO TOP • CONTENTS • NOTES
The buzz began in 2000, when Fredericson et al reported in the Clinical Journal of Sports Medicine that “long distance runners with ITBS have weaker hip abduction strength in the affected leg compared with their unaffected leg and unaffected long-distance runners.”139 Better yet, they found (or seemed to) that “symptom improvement … parallels improvement in hip abductor strength.”
This wasn’t a perfect study. It didn’t prove that weak hip muscles actually cause iliotibial band syndrome, or that strengthening them will cure it. The researchers showed only that — maybe — these things tend to go together: ITBS and hip weakness, sitting in a tree, kay-eye-es-es-eye-en-gee.
It was intriguing.
Beware! People, including scientists, are too easily impressed by correlations like this. Rather than causing iliotibial band syndrome, it’s possible — downright likely, in fact — that hip weakness could be a minor symptom of iliotibial band syndrome, collateral damage.140 But there was a lot of excitement about it anyway, and in 2005, drunk on his own Kool-Aid, Fredericson made the correlation mistake, publishing the indefensible opinion that hip strength does indeed cause ITBS,141 even though his original study had proven no such thing, and he hadn’t done any other research on the subject since then, and neither had anyone else.
Phase 2: The Hypening
A month later, someone else finally did: Niemuth et al published “Hip muscle weakness and overuse injuries in recreational runners.”142 Although they found the same association as Fredericson et al, that really was all they were looking for, the sample size was small, and they didn’t prove a causal relationship, which they freely and specifically admitted (“ … no cause-and-effect relationship has been established”).
In 2006, Lori Bolgla and a team at the University of Kentucky joined the fray. They studied various muscle strength and function measurements in relationship to patellofemoral pain syndrome,143 finding only a “moderate” association between that condition and weakness in one minor hip movement (external rotation), but conspicuously did not find a significant difference in the “main” hip strength movement: hip abduction.144 The authors clearly state — and no surprise here — that “we were unable to determine if hip weakness was a cause or a result.”
Still no smoking gun here. A definite absence of gunsmoke.
In 2007, Ferber et al completed another study.145 Despite never being published, both the researchers and media made way too much of the results — a damning example of science-by-news-release. “I think this is a good news study for people who are living with chronic running pain,” said Dr. Ferber. “You can do something about it.” Such optimism! Reporting on it for the Calgary Herald, Trent Edwards wrote (no longer available online): “While most running injuries happen in the knees and lower legs, it turns out their root cause is almost always weak hip muscles.” The whole thing has a weird eureka tone, as though a great mystery had been officially solved. But Dr. Ferber was clearly ahead of himself. Everyone loves a root cause!
Patients bring such media reports to me in a tizzy of optimism, and I have to be the wet blanket. I have to explain that — just like with every other Holy Grail of biomechanical theorizing — the jury is not just “out,” the trial had hardly even begun. A dozen necessary studies were still missing in 2007. Reaching a conclusion based on the evidence back then wasn’t just difficult, it was impossible in principle.
Not much else happened for three more years, while the hype marched on and the researchers continue to promote their hypothesis.146147 The promotion is obvious in a general review of running injury mechanisms in 2009,148 and then again in 2010, in a paper which did not even present good evidence of correlation, let alone causation.149 Those were paltry scientific contributions, and I dropped the topic in a bit of disgust at that point. And so could you. Skip this next bit if you’re already convinced/disappointed, because there’s very little to add, and what little there is mostly just confirms that this is a dead end. But I am obliged to be thorough, because that’s what you paid for.
Like cold fusion, but with smaller press conferences
When there are signs that a scientist may be just a little too fond of their own exciting hypothesis, eventually other scientists come along and try to find the same thing … and usually fail. Like cold fusion, but with smaller press conferences.
The first example of failed replication of the hip weakness hypothesis was in 2007, just as the hype was really surging. Grau et al said everything I’ve already said above, but more formally, with a paper titled, “Hip abductor weakness is not the cause for iliotibial band syndrome.”151 They did a tiny test of strengthening to see if it would help, comparing hip strength in ten runners with and ten without IT band syndrome. There were no meaningful differences, and “strengthening of hip abductors seems to have little effect.”
Which was followed by years of scientific silence. During which time tens of thousands of runners were told by well-intentioned clinicians to strengthen their hips to prevent/treat ITBS. They all thought they were practicing not just evidence-based medicine, but bleeding edge EBM. Ruh roh, Raggy!
Fast forward all the way to 2014: a small paper reported only one minor part of hip strength was detectably weak in injured runners — internal rotation — and it was hardly a big difference.152 “Teensy” is the technical term for that kind of difference. And while internal rotation is indeed part of the biomechanical equation, it’s hardly what people are thinking of when they think of hip strength. “Obscure” is the next adjective that comes to my mind.153
There’s only one more scrap of science I know of, in 2015, yet another small one (of course), reporting a modest weakness in hip strength — the more familiar kind, abduction — but only in runners with previous IT band syndrome.154 Runners with current ITBS … well, that was just a big fat nothing burger. No link at all. And the link with previous cases hints that what little weakness they found might well be a long-term consequence of being injured, not a cause.
There’s no other science to report on except a few review papers, formally trying to make sense of the same inadequate evidence I’ve been weighing here, some of them concluding that there may or might or could be a link possibly, perhaps. But others, like Louw et al, have more honestly concluded that, duh:
The literature is inconclusive with regards to muscle strength deficits in runners with a history of ITBS.155
So the whole thing just reeks of “pet theory” syndrome, and it’s extremely unlikely that hip weakness causes IT band syndrome. And therefore it is also extremely unlikely that strengthening hips will prevent or treat it.
Why not strengthen your hips anyway? Who doesn’t want stronger hips?
You probably have better things to do than progressively load obscure muscles that probably have nothing to do with ITBS. But I suppose if it was me, if my own case of ITBS made a comeback and got really stubborn, I might do it anyway. It’s certainly not going to hurt anything. I can’t endorse it, but I don’t object to it either.
Just go in with your eyes wide open. You might be wasting your time. Just like five hundred soldiers who already tried it on your behalf …
Here’s one more bit of discouraging science I held back for a punchline. This was not a small experiment: it was a huge test of a thousand soldiers that failed to show any (injury prevention) benefit to hip strengthening. Although one study is never enough to settle an issue, this one almost could. The results were published in 2008 in the American Journal of Sports Medicine.156 500 soldiers did both stretching and strengthening exercises chosen to try to prevent overuse knee injuries. Hip abduction was included, specifically because of the hype about hip strengthening: because of the prominent papers pushing it as a possible risk factor. 500 more soldiers did no exercises for comparison.
Results: the injury rates in the two groups were … almost identical. And what difference there was between them was (slightly) different in the wrong direction. The group that did no exercises actually had slightly fewer injures: 48 injuries instead of 50.
Generic hip strengthening is definitely not preventing IT band syndrome. And if it’s not preventing it, it’s not going to treat it either.
A scrap of data about hips tiring out faster in ITBS patients
In 2019, Brown et al reported on the results of a teensy little trial, contributing just a little bit of indirectly relevant data.157 They took some measurements of a couple hip muscles, gluteus medius and tensor fascia latae, before and after running on a treadmill until they were worn out. They were mainly trying to determine the effect of running on the strength and responsiveness of hip muscles, which is kind of an oblique take on the central question.
Unsurprisingly, hip muscles got weaker after hitting the treadmill so hard, and equally so in both groups. Despite that, the authors conclude — on the basis of one other single metric — that the gluteus medius “does demonstrate less resistance to fatigue,” slightly. In other words, they found one subtle and technical sign, in just 12 injured runners, that was more “suggestive of fatigue” than the other signs. Scraps of evidence don’t get much thinner.
They wrap up by recommending strengthening of the gluteus medius, as though their data demonstrated a need for that. It does not. If gluteus medius actually does have poor fatigue resistance in runners with IT band syndrome, there’s no specific reason to think it isn’t just a trivial symptom of the condition — rather than a defect that needs correcting.
GO TO TOP • CONTENTS • NOTES
There are several different kinds of therapeutic massage and self-massage options for iliotibial band syndrome. None are based on any scientific evidence. A couple approaches are sensible enough, and their value might be confirmed by research someday. Several other massage therapies for IT band syndrome are probably a bad idea. The next three sections discuss the three primary popular options: IT band massage (long strokes on the side of the thigh), trigger point therapy (primarily for the hip musculature, but not exclusively), and transverse friction massage.
Direct massage of the IT band — pressure on the band itself and the underlying quadriceps muscle — is by far the most common kind of massage therapy offered for IT band syndrome. It’s also probably the most simplistic and useless. If you are a manual therapist who has employed these methods, please forgive my particularly intense disdain for them.158
Typically, strong Swedish massage is used to “lengthen” the IT band and/or “unstick” it from the underlying quadriceps, and the intention of this treatment is rarely any more complicated than that. These approaches to ITBS have a cave-man level of therapeutic sophistication: “IT band hurt, ugh! Therapist Thag must rub IT band!” Patients are routinely instructed to perform the same massage treatment on themselves using a foam roller at home. It’s a painful place to massage strongly. In this section, I’ll show that it’s also pointless.
Some therapists may also claim that the underlying quadriceps (vastus lateralis) muscle is an additional target of the treatment, but they’re unlikely to have a clear idea how quadriceps massage is supposed to help, and the focus of the treatment will still be on the IT band itself, which is probably futile.
Graston Technique® or Astym® (or the Chinese gua sha) are variants of IT band massage that are quite savage, using wicked-looking stainless steel “scraping” tools to allegedly break down tissue adhesions. They are not as common as the other methods, but I pick on them because they are painful and costly and so focused on the dubious idea of treating the IT band itself.
So what’s the problem with these treatments? They are all based on poor understanding of the condition, the anatomy, and of connective tissue.
The iliotibial band is a massive structure, the largest tendon in the body, made of a bio-rope stuff that is slightly elastic but with a greater tensile strength than steel cable. Collagen is an extremely tough protein. It cannot be elongated beyond its natural elasticity by any known method short of surgery, and certainly not by rubbing it or (even sillier) rolling over it. Here’s an absurd little thought experiment to demonstrate how silly it is:
- Measure a leather belt.
- Lay the belt out on the edge of a table.
- Grease up your elbow with some lubricant.
- Slide your elbow along the length of the leather belt. This patient feels no pain: be as brutal as you like!
- Re-measure the belt. How’d you do? Make much progress?
Now consider that leather is actually much less strong than tendon. Leather is cow skin — remarkably tough, but with a lower tensile strength than tendon, and much easier to tear. Tendons are so tough that they basically don’t tear at all, ever.159 Yet even if you halved the thickness of that belt, hung it from a strong hook in the ceiling, and pulled on it with all of your body weight, it would probably still hold you.
So … good luck trying to “elongate” the IT band with massage.
Even if you could elongate the IT band by rubbing it, this would surely not be the smartest way of doing so. This is a tendon we’re talking about here: tendons tie muscles to bones. If you want to change the tension on a tendon, change the behaviour of the muscle. Changing muscle tone is not exactly easy either, but it’s certainly more plausible than beating the IT band itself into shape. Consider this: if you want to loosen your hamstring tendons, should you massage the tendons, or the hamstring muscles? The muscles, of course!
There’s a dead giveaway that therapists who do this treatment are really not thinking it through: they usually ignore or minimize the hip muscles, the same muscles that actually control the tension on the iliotibial band.160 In my many years working as a massage therapist, I asked many clients, “Did your previous massage therapist work on muscles in your hip at all?” They routinely replied, “Nope, just the side of the thigh.”
What about thixotropic effect? Some therapists might try to argue that “thixotropic effect” is the method behind their madness. This is just a straightforward abuse of the concept — it doesn’t mean what they think it means. Thixotropic effect in physiology is the tendency of certain tissues to become a little softer when kneaded or stressed. This is a real thing.161
However, thixotropic softening is a minor and transient response with no effect at all on the length of the IT band, only its pliability; and, whatever effect thixotropy has, the IT band rapidly reverts to its previous state after treatment, like a piece of warm plastic thrown into a snowbank.
What about breaking adhesions?
Some therapists justify IT band massage by arguing that the IT band is literally “stuck” (adhered) to the underlying quadriceps, and that this accounts for IT band tightness. This is a popular concept. While thixotropy is obscure, adhesions are downright popular — you’d have trouble finding a therapist who didn’t bring them up in this context. But discussing adhesions here hopelessly mixes up the ideas of elasticity, tightness, and freedom to slide.
Like thixotropy, adhesions are a real thing — tissues can become stuck together by a slight chemical bonding of hydrogen atoms that protrude from the surfaces of connective tissues like the hooks and loops of Velcro. But the elasticity of tendon is determined entirely by the molecular structure of the protein molecules that make it up162 ... not on the ability of layers of connective tissue to slide over each other.
Unfortunately, the adhesions justification is particularly wrong because it ignores the normal anatomy of the IT band, which is actually anchored to the femur for most of its length — it’s not free to slide in the first place, so it can hardly be deprived of that power by adhesions! You can’t “free” what was never pathologically stuck to begin with. Short of quite a bit of messy work with a scalpel and cutting the IT band free of its moorings, you can’t make the IT band available for sliding.
And, equally important, even if you could “free” the IT band, you wouldn’t really be “loosening” the IT band, not in the sense of making it more slack, which is clearly what IT band massage is supposed to achieve. A tight IT band could, in principle, slide just fine — if it were free to slide. Muscles and tendons generally do slide over underlying structures, tight or not. “Freedom to slide” and “tightness” are simply not the same thing.
As if it weren’t bad enough already, the adhesions justification gets sillier still: adhesions probably don’t even exist under the IT band to any significant degree anyway. Such adhesions are a clinical problem only in people who are significantly immobilized due to paralysis, and even then adhesions can be broken up relatively easily — this is just stickiness, not scarring. In active people — like virtually all patients with IT band syndrome — it is basically impossible to develop any significant adhesions anywhere in the body.
So, adhesions probably don’t exist in this location, have nothing to do with IT band tightness at all, and can’t prevent sliding powers the IT band never possessed in the first place. It’s therefore a good mystery why therapists are so busily trying to break them.
What about the quadriceps muscles?
Some therapists may argue that long, deep strokes up and down the length of the iliotibial band are actually intended to massage and treat the quadriceps. Foam rolling is often recommended as a delivery system for those strokes. It’s a popular self-treatment for the thighs, regardless of IT band problems. A 2012 trial of foam rolling is the first of its kind: Macdonald et al measured its effect on knee range of motion in healthy men and reported a small, temporary boost, but that sure doesn’t prove much — and the study was small and inconclusive in any event,163 the tip of a research iceberg that doesn’t exist yet.
Trigger points in the quadriceps might contribute to pain and feelings of stiffness and dead heaviness in the thigh and knee. To the extent that typical Swedish massage of the quadriceps relieves those possible trigger points — which it might, though not so well as deliberate trigger point therapy — it might provide some temporary symptom relief only.
“Happier” quadriceps musculature could also lead to slightly altered hip and knee function, and this could conceivably result in changes in IT band syndrome — but would those changes be beneficial? Lasting? Or significant? No one knows any of that, but perhaps. I will devote a separate section to this approach shortly, though, because it’s at least promising. Alas, happy quads are rarely the actual goal of professional massage therapy — the fantasy of IT band lengthening is much more likely to be the focus of treatment.
Graston Technique® and Astym®: Scraping the IT band with hard edges
Instrument-assisted soft tissue mobilization (IASTM) techniques (best known as brands like Graston Technique® and Astym®) are the coup de grâce of this parade of inanities. IASTM is mainly intended to break down scar tissue and adhesions, and/or to force tissue adaptation with an intense, mildly damaging stimulus (provocation therapy).
This rationale is appealing to many patients — “We are going to tenderize the IT band!” — but meaningless. IASTM is scientifically bankrupt.164 A systematic review of several studies of it in 2016 concluded that it produces only “insignificant results which challenges the efficacy of IASTM as a treatment for common musculoskeletal pathology.”165 That evidence is incomplete and does not rule out the possibility that it could work on IT bands, which are obviously a bit of a special case, but it is quite damning. It’s not the last nail in the coffin for IASTM, but it’s probably one of the last.
And the IT band may be a special case, but if anything it’s less likely to respond meaningfully to scraping than other structures.
I explained above the IT band is so incredibly tough that it’s a complete fantasy that it can be lengthened with massage. If you wanted to try, though, maybe the steel tools of Graston Technique would do the trick? Not likely! Consider the leather belt analogy again: I don’t think any amount of force (that the patient could tolerate) would do the trick, and possibly no amount of force at all would work.
“Scar tissue” is a bogeyman that has absolutely no place in this discussion. No one is scarred without an injury. So why would anyone’s ITB in particular be scarred without an injury? Therapists who talk about scar tissue where there has been no injury have simply wandered away from physiology and into marketing language. Unfortunately, this is common.
Adhesions are sometimes imprecisely portrayed as a type of scarring, but that’s misleading: they are fundamentally different. And adhesions, as discussed above, are not clinically relevant to ITBS in any case.
There is just no rationale for IASTM that is consistent with what is actually known about the nature of connective tissue or iliotibial band syndrome. Furthermore, it is such an aggressive approach that there are several ways in which it may simply add injury to injury.
Finally, some good news
This has been a long section about a lot of things that don’t make much sense and probably don’t work. Fortunately, we can end it on a simple, positive note: a perfectly good reason to try “elongating” massage, even foam-rolling … just not focused on the IT band itself, but on the muscles that control tension on the IT band.
Massage literally loosens muscles, a little bit, temporarily, probably. A few firm massage strokes along the length of a muscle — parallel to the fibres — increases the flexibility of the muscle.166 It’s almost certainly a neurological effect. It’s not breaking up adhesions. It’s not melting anything. It’s probably just temporarily changing the behaviour of the muscle with some sensory input.
Do this to the right muscles, and it probably can reduce tension on the IT band. It’s not a big deal, but at the right intensity it feels nice and it may provide some (much needed) temporary relief. Bringing up the rock-in-shoe analogy yet again, loosening your laces doesn’t exactly solve the problem, but you probably still want to loosen your laces.
The muscles that cinch up the IT band are:
- gluteus maximus
- the tensor fascia latae
- the peroneus longus (a little known curveball)
All of these are worth massaging in the context of trigger point therapy as well, so I’ll defer detailed instructions to that section, which is not far below.
Massaging the IT band itself, even though it may have no mechanical effect, might have a sensory effect. In other words, because it’s essentially a giant tendon for the gluteus maximus and tensor fascia latae, it’s possible that massaging it has at least some of the same effect as massaging the muscles themselves. This might even be why so many people swear by foam rolling of the IT band. But they would probably get better results if they focused on the muscles rather than their big tendon.So I’ve come full circle here, and tentatively endorsed a little IT band massage … just for a completely different reason than any of the ones normally tossed around. 😜 And with the important caveat that it’s probably not the best target.
GO TO TOP • CONTENTS • NOTES
A reader reported a craaaazy example of dangerously unwise therapeutic advice — an instant classic for my files. Extreme medical incompetence always makes for a good story … and a teachable moment. I think it’s important for readers to see just how far wrong therapy can go, how illogical and unreasonable it can be. This story will give you a disturbingly clear sense of how irrational and foolish the devotion to conventional wisdom can be!
It all started with a steroid injection for knee pain. As you read above, steroid injections are a reasonable treatment option, worth a shot in tough cases. Unfortunately, no treatment is risk free, and she demonstrated this in spades, with a rare and particularly severe negative reaction to the shot: a phenomenon sometimes called “steroid flare.” The result was an evil welt running up the side of her thigh: “super red, hot to touch, swollen, hard” and so painful she could barely touch it.
She was understandably alarmed, and she returned to the doctor’s office. Stunningly, she was told on the spot to go home and “roll it” — an intense massage technique, pointless and ineffective at the best of times, but actually awful and dangerous in these circumstances. He might as well have told her to massage an open wound, or to treat a fracture with a hammer — a few good whacks should help!
She didn’t do it, of course. She was horrified, and promptly moved on to another doctor, who immediately declared the prescription to be the stuff of malpractice. Obviously!
It’s always frustrating and morbidly amusing how illogical treatments persist in health care. As I mentioned, I have seen many cases over the years of rolling and other intense IT band massage being prescribed in inappropriate circumstances. For instance, patients often mention that foam rolling had been prescribed to them for other knee conditions that have nothing to do with the IT band whatsoever, and couldn’t possibly be treated by rolling even if rolling did work for IT band syndrome — multi-dimensional wrongness!
Was this professional blind? Or sadistic? How is it possible to be that incompetent? It’s hard to know what to make of it. And it’s disturbing that people like that can get through our schools and get certified.
The cherry on top of this story is that the patient had read this book and was well aware that rolling is not much of a therapy, and she said so. The doctor’s bizarre emotional response was to evade the obvious issue — the insanity of massaging a severely inflamed welt — and to double-down with an emotional, stubborn lie. He blustered, “The evidence does support foam rolling.” That was nothing but a clueless bluff. There is no such evidence.
Bad treatments are often recommended for incredibly bad reasons, but this is definitely one of the best examples of it I’ve ever seen.
GO TO TOP • CONTENTS • NOTES
We’ve already established that trigger points (muscle knots) might be partially relevant to iliotibial band syndrome, because they could cause shortening of the muscles that increase tension on the IT band and/or because they may screw up hip function a bit (causing weakness, poor coordination). We have some credible reasons to believe that trigger point therapy might be an effective treatment — no hard evidence, but certainly much better reasons than we have for massaging the IT band directly (which is commonly done). Just as the problem can be treated with a loosening surgical snip on the side of the IT band, it might also be loosened a little with thumbs instead of knives. And if there is any truth to the theory that hip weakness matters, then it might be worth trying to help those muscles.
Conveniently, trigger point therapy also overlaps with simple longitudinal massage, which I cautiously endorsed above. You can do both at the same time! Indeed, it’s hard not to. And both techniques may help loosen things up in different ways. Even if one is bunk, the other may not be. Each concept is “Plan B” for the other.
Optimism must be tempered by the knowledge that “tightness” per se is probably not the problem, that the need for hip strengthening is mostly hype so far, and even the science of trigger points itself isn’t exactly rock solid either — it’s just a label for the murky phenomenon of focal muscle pain. While I think that trigger point release in the IT band muscles is probably a little relevant to ITBS, in practice I think it yields only a minor benefit to the condition. Trigger point release is an uncertain business, and hip trigger points in particular have an unusually stubborn character, nearly impossible to get rid of completely. People’s hips tend to be full of sensitive spots, no matter how much therapy you do.
If you can pull it off, will a small amount of temporary IT band loosening — compared to surgery, say — even help IT band syndrome? Recall that IT band loosening as a treatment is analogous to loosening your shoelaces to try to deal with a rock in your shoe. If the rock is still there, a looser shoe is indeed better than a tight one, but the problem isn’t solved. IT band tightness may be relevant to ITBS and may be affected by massage of the hip muscles, but it’s unclear whether even a successful massage can loosen the IT band at all, let alone enough to make a difference.
Go pro? Although it would certainly be ideal to try trigger point therapy applied by a skillful and experienced therapist, it’s expensive — especially for a therapy that may not work no matter how competently it is performed. Therefore, self-treatment using your own thumbs and simple tools is a surprisingly good option — cheap, safe, and probably nearly as effective as professional therapy, especially with a little practice. Plus, it also has other benefits.167
Despite its many uncertainties, trigger point therapy is easy to try: it’s really just a matter of applying pressure to key locations in muscle tissue … and it’s hard to do something wrong when nobody really knows how it’s supposed to be done. That leaves you free to experiment!
Basic trigger point massage
To treat trigger points, first feel around for unusually sensitive and aching spots in your muscles. For basic trigger point massage, don’t worry about trying to find lumps or bumps — just judge by the sensation alone. Choose three to five spots to work on for a few days. Return to each of them each day.
Gently knead the tender spots for a few seconds with fingers or thumbs, or press firmly until the sensitivity eases. Your goal is not to manipulate meat in any particular way, but simply to create sensation, to “scratch the itch.” Err on the side of gentler — most people tend to be too brutal with their own trigger points, especially at first. Give a little more attention to spots that produce “good pain,” and be more cautious with those that simply feel nasty.
Spend five to twenty minutes on a massage session. Do one to three sessions per day for up to a week or so. There’s only so much time most people should spend below the knee on this challenge. Success feels like clearly reduced sensitivity over a period of days, and/or reduced IT band pain symptoms. If it’s not reasonably obvious that you’re making progress, you probably aren’t making progress.
Almost anything can happen, and — strangely — failure means nothing in particular. It could mean that you have no meaningful trigger points at all and it’s not worth your time to continue. Or it could mean that you have unusually severe and stubborn trigger points, and you need to learn much more about muscle pain and try much more advanced self-treatment strategies. That is why I provide a free extra tutorial to every customer who buys this one.
If massage does not work, how hard and long should you try? Who should consider getting more serious about trying to treat trigger points? For many patients, IT band pain and other primary chronic pain problems are tips of icebergs. If you’ve suffered from many body pain problems over the years, and IT band pain just happens to be the one that’s bugging you the most at the moment, then it’s probably a good idea to learn more about muscle. Or if the soft tissue in your lateral thigh and hip seems to be quite rotten with sensitive spots, that too is probably a good excuse for delving deeper.
Sensitivity in muscle tissue is poorly understood and sometimes will not respond to anything you can do to the muscles. And it may or may not matter to IT band pain. (I promised to keep my enthusiasm in check, remember?) But it is worth trying.
Five key locations to explore with trigger point therapy
- Tensor fasciae latae (TFL). The IT band is the tendon of the TFL muscle. It is a short muscle descending from the front of the hip. For more about the tensor fasciae latae, see below.
- Gluteus maximus. In a curious arrangement unique in the body, the gluteus maximus attaches to the side of the IT band, pulling on it the same way that an archer pulls on a bowstring — except that it’s pulling on one end of the string. For directions on self-treating the primary gluteus maximus trigger point, see Perfect Spot No. 12.
- Gluteus medius and minimus. These two almost identical muscles are on the side of the hip. They do not control IT band tension. However, they are a significant part of a common pattern of muscle crankiness in the region. Arguably, you cannot successfully relieve gluteus maximus and tensor fasciae latae trigger points if you do not also relieve them in the gluteus medius and minimus as well. To some extent, that is true of every muscle in the region — however, I suspect the gluteus medius and minimus are the most important. For more information about treating these muscles, see Perfect Spot No. 6.
Click to embiggen. The gluteus minimus & medius muscles are shaped like slices of pizza. (The minimus is hidden here: it is the same shape as the medius, but smaller & lying directly under it.) Perfect Spot No. 6 is usually found half way down the lateral edge, right on the side of the hip, in the “soft” area between the ridge of the pelvis & the big bone on the side of the hip (greater trochanter). But rather than being “soft,” the edge of the gluteus medius is usually quite rigid — almost as hard as the bones above & below!
- Vastus lateralis. The vastus lateralis muscle is the most lateral of four big sections of the quadriceps group. It lies partially under the IT band: while the IT band is right on the side of the thigh, the quadriceps is larger and extends further around towards the front. It has no control over the tightness of the IT band. However, massaging it may still relieve some symptoms in the thigh and knee. ITBS patients often have diffuse aching pain throughout the thigh. It’s not the main pain, but it can still be annoying. Vastus lateralis massage may relieve some of that discomfort, and that might in turn have some modest (and pretty unpredictable) effect on the function of the hip and knee. See Perfect Spot No. 8.
- Peroneus longus. This is a long, thin muscle on the outside edge of the calf. Just like the IT band runs down the side of the thigh like a stripe on a cop’s pants, so does the peroneus longus. Its main job is to point the toes (plantarflexion) and evert the foot (lifting the outside edge of the foot, an awkward little motion), but in its spare time it also applies some tension to the IT band — a minor contribution, but measurable.168 It is undoubtedly the least important listed here, but it’s a surprisingly nice muscle to massage, and you might as well be thorough. And there’s something aesthetically pleasing about extending the massage down the entire side of the leg — it seems right, for whatever that’s worth. Common trigger points in the peroneus longus are high and low in the muscle, a couple of finger widths below the knee, and 3–4 finger widths above the ankle bone.
Key locations for massage treatment of ITBS
More about the tensor fasciae latae muscle. Trigger points in the tensor fasciae latae are arguably the most important of the above, because it is the muscle that most directly controls the tension on the ITB. However, self-massaging it is a little tricky — it’s small — so I’ve never written an article just about that. And I never will — it’s just not an easy enough target for self-massage for the average person.
But for a motivated patient with ITBS? I think it is worth the effort.
Find the point of bone on the front of your hip. This is the “ASIS” (anterior superior iliac spine). Imagine the TFL hanging straight down towards your toes from that point: a span of 6-10 centimetres (2–4 inches) of muscle before it turns into the IT band. It’s not hanging off the front of that point, but more on the side of it, so if you try to come at it directly underneath the ASIS, it’s easy to miss. Instead, come at it from the side.
The key location is usually about 5 cm (2 in) below the ASIS.
On your own. Solo treatment of the TFL is best accomplished by trapping a ball between the side of your hip and the wall or floor. I recommend the wall at first, for better control.
With a buddy. If you have help, then treat this muscle while you are lying down, face up. Your buddy’s elbow comes at it from the side of the hip, pushing the TFL towards the center from its lateral edge, with a little bit of angling towards the floor as well, sort of trapping it against the femur.
Foam rollers. In the previous sections, I strongly criticized all massage of the IT band, which is generally what foam rollers are used for. However, foam rollers are certainly a good self-massage tool for the hip musculature, especially the gluteus medius and minimus on the side of the hip. And to the extent that vastus lateralis (quadriceps) massage is helpful for you, foam rollers are also quite handy for that.
Massage for the hip musculature may or may not have the desired effect on IT band syndrome, but it is definitely helpful for relieving stiffness and aching throughout hips (much the way we think stretching should be but often isn’t). Trigger point therapy has many benefits, so you may decide that it’s worth learning more and experimenting thoroughly, even if it does not help your knee.
GO TO TOP • CONTENTS • NOTES
Frictioning is a specific self-massage technique applicable mainly to tendinitis. It is another method (like icing) of stimulating tissue when actually using the tendon will probably just irritate it. The technique is simple: rub back and forth across the most painful spot on the tendon for five minutes, increasing the intensity a little bit whenever the sensitivity fades. If it doesn’t fade, stop for safety.
Frictions are generally not an evidence-based treatment: they haven’t been studied enough, and what little research has been done is not persuasive enough. Despite that, there’s strong expert consensus that the technique makes sense.169
Unfortunately, much less so for iliotibial band syndrome.
This popular tendinitis treatment — and convenient self-treatment — is a bit off the mark for ITBS simply because ITB syndrome is not a tendinitis.
The main idea of frictioning is that it’s a different kind of stimulation — rolling across the parallel fibres of the tendon instead of pulling on them, which is what got the tendon into trouble in the first place. This traditional rationale for friction massage simply doesn’t make sense if you don’t have a clear tendon fibre direction to rub across.
As discussed early in this tutorial, recent anatomical and biomechanical studies have showed that the ITB does not work much like any other tendinitis, and that it’s not even the tendon itself that is suffering. Instead, the pain is more likely caused by compression of the tissue underneath the tendon, just above the lateral epicondyle. If so, frictions on the tendon itself are probably barking up the wrong tree. And the evidence for frictioning ITBS is indeed pretty underwhelming: Loew et al found that studies of frictions for ITB syndrome showed “no benefit of deep transverse friction massage,” but they were also so flawed that “no conclusions can be drawn.”170
But all is not lost! Perhaps gentle provocation of the sore spot could still constitute a Goldlilocks-just-right degree of stimulation, regardless of fibre direction. If we embrace that, we’re abandoning the notion of “friction” and simply resorting to “gentle massage” of the side of the knee, which sounds like a pretty weak option to me — but it’s on the table.
And friction massage might actually work some magic in other ways, too. For instance, there are plausible neurological mechanisms for temporary pain reduction, or even more lasting reduction of pain. In some cases, where pain itself has made the knee more sensitive, frictions may be a way of training the sensitized area to tolerate stress again — another unproven but reasonable theory.
In any case, you can experiment with this technique with just a few minutes per day, so why not do it, just in case? No obvious reason I can think of, other than a low risk of simply irritating it, which is certainly not serious if you exercise a modicum of caution.
GO TO TOP • CONTENTS • NOTES
Nearly every ITBS sufferer tries to stretch their way clear of the condition. Stretching is a hot topic and a major part of the conventional wisdom, so I will really get into this in detail over the next three sections:
- A general introduction to the issues, especially the general scientific evidence
- The challenge of stretching the IT band specifically
- A suggestion for a better kind of IT band stretch
Stretching is over-rated as an exercise ritual,171 and there is definitely no good, direct evidence that any kind of stretching will prevent or treat iliotibial band syndrome. Try to find some — I dare you! The jury is out. No one has studied the problem well, and no one is likely to anytime soon. Meanwhile, the indirect evidence and expert opinion that is available on this topic is underwhelming and discouraging … at best.172173
There is a lot of evidence that generally trying to keep limber by stretching before workouts does not prevent injuries in general, including iliotibial band syndrome (which is, of course, one of the most common of all athletic injuries).174 The evidence is thoroughly described in the injury prevention section of my main stretching article, Quite a Stretch, but I’d like to describe one research example here in some detail: a 2008 study by American Journal of Sports Medicine that showed “no significant differences in incidence of injury” in soldiers doing preventative exercises for common overuse knee injuries, especially iliotibial band syndrome and patellofemoral pain syndrome.175
Half of the 1000 soldiers studied participated in an exercise program including five exercises for strength, flexibility, and coordination of the lower limbs, and 50 of those soldiers sustained overuse injuries in the lower leg, either knee pain or shin splints. The other 500 soldiers were doing nothing at all to prevent injury in the lower limbs — no specific stretching, strengthening or coordination exercises — and only 48 of them had similar injuries. There were “no significant differences in incidence of injury between the prevention group and the placebo group,” and the authors concluded that the exercises “did not influence the risk of developing overuse knee injuries … in subjects undergoing an increase in physical activity.”
The tested exercise regimen certainly did not work any prevention miracles for iliotibial band syndrome! This is what I meant above by results that are “underwhelming and discouraging at best.” Although better and more specific testing of IT band stretching can and certainly should be done, it’s reasonable to expect that benefits of IT band stretching should have shown up in this experiment … if the benefits exist. If 500 people can diligently do miscellaneous basic stretching and still get hurt just as much (a little more!) as 500 guys not doing the stretching … well, how good can it possibly be?
Not only is the IT band an extremely difficult structure to stretch (see next section), but it is debatable whether ITB “tightness” is even a basic problem (see way above).
Nor is it safe to assume that stretching works based on the say-so of your physiotherapist, or your fellow runners who swear by it, or because it’s recommended by almost every article on the internet about iliotibial band syndrome. Stretching enjoys an absurdly inflated and unjustified popularity in our culture, but there are many problems with it, and it might very well be a waste of your time.
Don’t believe me yet? That’s okay — we’re just getting started on this.
GO TO TOP • CONTENTS • NOTES
How much does the standard IT band stretch actually “elongate” your IT band?
It’s not easy to stretch the iliotibial band. Not easy at all. In fact, it’s possible that it’s impossible.
The most common kind of stretches recommended for the iliotibial band are also the least likely to be effective, simply because they are focused on stretching the iliotibial band and the tensor fasciae latae muscle, and there is no good way of applying any significant amount of stretch to these structures. Not everything in the body can be stretched, just like not every muscle can hoist a heavy barbell.176 There are biomechanical difficulties with stretching some anatomy:
The hip joint and shorter hip muscles are the structures that limit range of motion in an idealized stretch of the iliotibial band. This was competently demonstrated in 2016 by Willett et al,177 discussed above in the tightness section. Their point was to test a test. Specifically, they were testing “the Ober test,” which is a test that supposedly measures the tightness of the IT band. What they found was that it did no such thing. Instead, it was measuring the “tightness of structures proximal to the hip joint, such as the gluteus medius and minimus muscles and the hip joint capsule.”
If you can’t test the tightness of the IT band that way, then you can’t stretch it therapeutically either. The Ober test is a theoretically ideal stretch, and it’s not actually stretching the IT band (or not primarily). Other structures get in the way, and the structures we want to stretch — the IT band and the muscles that pull on it — are hard to apply tension to …
- The iliotibial band itself is just too tough to be stretched, even if you could pull on it very hard indeed. Smaller tendons that are easy to pull on are extremely difficult to elongate, requiring long hours of painful stretching such as dancers and gymnasts do. But the ITB is the longest and most massive tendon in the human body. It’s also not free to move like most tendons: it’s anchored along the length of the femur.178 How can you “stretch” a tendon like that? Imagine bolting a two-foot strip of thick tire rubber to a plank of wood in several places. Now try to “stretch” it! You might be able to apply some tension to it, but it’s certainly not going to elongate significantly.
- In addition to its extraordinary toughness, the IT band is also probably more elastic than most tendons, as a functional feature.179 This is not a contradiction: things can be both extremely tough and elastic (like these super rubber bands — unbreakable, but still elastic). Whatever elongation you can get out of an IT band is only what it allows by nature — you can’t stretch it past that point, and by nature it will snap back to its resting length effortlessly, as though you never did anything.
- The tensor fasciae latae, the muscle that most directly controls tension on the iliotibial band, is the most promising target for stretch. It is a hip abducting muscle, so to stretch it you primarily have to adduct the hip: that is, the leg must move towards the midline. But there is not much movement available in that direction: the other leg is in the way. The best that anyone can do is to cross the (stretch-side) leg over the other leg, and push the pelvis out. It is possible to stretch the TFL and IT band in this manner … but not strongly.
- The gluteus maximus is mostly unstretchable: a surprisingly long muscle, it is just impossible to flex the hip enough to apply much tension to it, because the thigh meets the belly too early … even in a skinny person. In someone with a bit of belly fat, it’s hopeless.
The usual IT band stretches are missing a crucial component: knee flexion. For any hope of stretching this structure, you simply have to include knee flexion. And yet almost no one does. It is rarely prescribed or taught correctly.180
As discussed above, the iliotibial band does not have a well-defined attachment point on the knee, the way most tendons do. Instead, it spreads out and blends into the capsule of connective tissue that surrounds the knee. Thus, knee position clearly affects tension on the iliotibial band — and it has long been recognized that the iliotibial band is tightest around 30˚ of flexion.181 An iliotibial band stretch without knee flexion is just not much of an iliotibial band stretch.
Another element that is important but often overlooked is “anchoring” the pelvis. The IT band “hangs” from a “hook” on the front of the pelvis called the anterior superior iliac spine (ASIS). If you want to stretch something attached to the ASIS, the ASIS has to be held still, or pulled the other way. Just lean your torso away from that corner of the pelvis. This takes up the slack in the lateral and anterior abdominal muscles, pulling up on the front of the pelvis. Raising the arms too: that takes up a lot of slack in the very long latissimus dorsi muscles, which tighten the broad thoracolumbar fascia like a girdle, also helping to anchor the pelvis.182
No elongation: you can’t make your IT band longer
Even if you do everything right, even if you perform the ideal stretch and manage to pull firmly on your IT band for a couple minutes — which is longer than most people ever bother — how much would you actually change the length of your IT band? How far would it move?
Roughly 2 millimeters — an overall change in length of less than half a percent.
You still won’t actually change its length, any more than you can make a leather belt longer by pulling on it. This is the most important thing IT band stretchers need to understand.
In 2010, Irish researcher Dr. Eanna Falvey and her colleagues measured the mechanical effect of a basic IT band stretch (like the standard one illustrated at the beginning of the chapter) plus a more sophisticated stretch, and found virtually no difference: the IT band was effectively unaffected. And that was including knee flexion, in a stretch carefully applied to corpses by anatomists!183184 In an even more aggressive experiment in 2017, the IT band was completely excised, washed, frozen, thawed, and machine-stretched … and it still stretched only a few millimetres.185
If those tactics can’t elongate the IT band, runners don’t stand a chance.
And so, unfortunately, conventional iliotibial band stretches, prescribed and described practically everywhere — even the better ones — are simply not able to do the job. Assuming it’s even a job worth doing.
GO TO TOP • CONTENTS • NOTES
If there is any hope for any kind of stretching for ITBS, obviously we need to let go of the idea of actually changing the IT band. Instead, it may be smarter to aim for changing its behaviour — how it responds to usage and stress. This might be achieved with a dynamic stretch or mobilization that tries to put as much tension on the IT band as possible in a functional context — to “stretch” it while moving. What kind of stretch includes knee flexion and anchors the pelvis while we’re moving? The best solution I have found for this challenge comes straight out of taijiquan.
I discovered this IT band stretch by accident, and only later worked out why it works biomechanically. Trying to do t’ai chi when I had acute ITBS, I learned the hard way that this particular movement was by far the most painful thing I could do to my own knees. It produced an extremely clear sensation of “cinching up” around the knee,186 and it was obvious that no other movement was so challenging and provocative to the lateral knee.
I have no idea if this dynamic stretch actually works, and I’m not even sure that it is even safe. I am suggesting it primarily as a theoretical “ideal stretch” for readers determined to try stretching. All I know for sure is that it certainly creates tension in the IT band, and that it forces the IT band to do its “job” in a big way — that is, it pushes the IT band to do what IT bands do (stabilize the lateral knee).
Ironically, that also means that the exercise maximizes stress on the IT band, which could be bad news — and is probably completely at odds with the need to rest an overuse injury. Although your goal is to “loosen” the band, you are actually trying to tighten it when you stretch. If the side of your knee is unusually irritated, than any successful stretch should in principle irritate the problem! And by adding knee movement as in the mobilization exercise described here, the risk of aggravation is even greater, because you are applying a stress repeatedly. So you should use this stretch with some caution and only as your symptoms allow. I do not recommend doing it at all in the first few weeks of ITBS. It is probably much safer in the later stages of recovery, when there is less risk of re-irritating the knee.
Numerous readers have asked me to clarify exactly what I mean when I say things like “as your symptoms allow” or “the first few weeks.” Of course, I’ve been imprecise because it is a difficult thing to be precise about! Telling someone at exactly what stage of recovery to try something risky is somewhat like trying to tell an investor whether to go for the glory with volatile stocks, or stick to bonds and mutual funds. However, here are a couple ideas:
- To help determine how much of a problem early stretching might be for you, stretch early! Stretch while your symptoms are acute with the deliberate intention of provoking an aggravation, just so that you can determine how much stretching affects you. Then use that reaction as a guideline for future action. If stretching clearly aggravates your symptoms, then you should avoid it for longer. If it doesn’t seem to have much effect even when your symptoms are acute, then you can re-introduce stretching as a therapy sooner.
- Or, avoid stretching entirely until you reach an arbitrary “safe” point in your rehabilitation (i.e. one hour of running with no pain), and then re-introduce it slowly … but try doing it after runs so that you can tell if it causes any problems.
In any case, when you do try stretching, just bear in mind that there is risk.
Iliotibial Band Mobilization — The iliotibial band mobilization is a dynamic stretch that occurs as you are moving, teaching the muscles that control the tension on the ITB to be responsive, shortening and lengthening as needed. By “freezing” the movement in the right place, you can also stretch the ITB more powerfully than by any other method I know of. Begin by standing. Step forward the distance of a normal stride, placing your front foot in line with your back foot or even slightly across the midline. The toe of the forward foot should be pointed outwards. The forward leg is not the leg you’re stretching—the back leg gets the stretch. Crouch deeply, lowering the knee of the back leg almost to the ground. As you do so, push your hip (of the back leg) out to the same side, and your knee (of the back leg) to the far side. Then stand up, step forward with your other leg, and repeat on the other side. Another important element of this mobilization is arm movement (not shown in diagram). It may take some practice to integrate this step, especially while moving. However, the stretch is strengthened significantly by reaching up and away from the stretch side. That is, when dropping the right knee and stretching the right ITB, reach upwards, backwards and to the left, leaning away from the front right corner of the pelvis. Here’s a video of the stretch being doing mobilization-style (continuously moving in and out of the stretch, rather than holding it).
That picture gives you a basic idea, but it’s not enough. And so now, after much procrastinating … I finally — it took me literally many years to get around to this — produced a demonstration video of this tricky exercise! It’s even kind of funny.
When the time comes to stretch, how much is right? If it’s feeling good, do a set of about a dozen before running and perhaps another set afterwards and maybe even a third set at some other time of the day. If it continues to feel good, great … you could probably go up to twice that many.
And one reader asked “How fast?” You should probably start slow, but speed and intensity can increase along with frequency.187
So, that is a reasonably effective way of “stretching” the iliotibial band — plus it’s a dynamic stretch, which means that the IT band is doing something, that you are challenging that tissue to do what it does best. Although you can freeze the motion at the peak tension on the ITB for a theoretically ideal static stretch, the movement involved has a lot going for it.
In fact, the concept of mobilizations is quite important …
GO TO TOP • CONTENTS • NOTES
In the previous section, I introduced a method of stretching that is probably the best possible way to pull on your IT band, for whatever that is worth, but it was also a dynamic or moving stretch — technically a different beast than just stretching — known as a “mobilization” or “dynamic joint mobility drill.”
Another promising alternative to the usual ITB stretches is to stretch and mobilize the lateral hip musculature specifically, especially the gluteus medius and gluteus minimus. As discussed above, weakness of these muscles is implicated in iliotibial band syndrome by some evidence, even though it’s not particularly persuasive evidence. And they may be weak because they are full of muscle knots, and muscle knots may make strength training difficult or even cause it to backfire.
Stretching, mobilizing, and massage (discussed separately) could help. The rhythmic, repeated movements of mobilizations alternately stretch and contract musculature and other soft tissue — massaging your tissues with movement. I generally recommend mobilizations in preference to stretching because they are more neurologically interesting than stretching, and they stimulate more metabolic activity in the tissue. They are more practical and efficient than stretching in many ways, especially because they can affect more tissues more quickly, and because they constitute both a better warm up and a better warm down for more intense activity. See Mobilize! for more information.
Stretching is not a reliable treatment for trigger points, but it is generally worth trying — sometimes it relieves muscle pain and stiffness. Although stretching is the first thing everyone tries to do for stiff, sore muscle, in practice results are erratic and usually minor at best. If trigger points are “mini cramps,” stretching might help some of them — or it might be more like trying to untie knots in a bungie cord by pulling on them. That topic is covered (very) thoroughly in the trigger point tutorial, and summarized in my main stretching article: Quite a Stretch.
Yet again, we have no proof — or really any direct evidence at all — that this will work. In fact, if anything, there is evidence that it won’t! As already discussed in the sections above, we know that stretching is generally a proven loser when it comes to preventing injuries, so it’s implausible that these refinements are going to change that.
On the other hand, perhaps this is more than just a “refinement.” There is a big difference between conventional IT band stretching and typical leg stretches versus a more thorough program of mobilizing and stretching with more skill and different intentions. Combined with other treatments for the hip musculature, like actual massage in addition to “massage with movement,” it might all add up to something genuinely better than standard IT band stretching. It’s all probably worth a shot if you’re frustrated with a stubborn case of iliotibial band syndrome. Let me put it this way: it may not be proven, but stretching and mobilizing the hip muscles generally makes more sense than conventional IT band stretching … which isn’t proven either. So if nothing else, this approach at least constitutes a sensible substitute for the kind of stretching you were probably determined to do before you started reading this tutorial.
Call it an “upgrade,” then.
So, how do you do mobilize the hip muscles?
Certainly you could do worse than the dynamic stretch of the IT band described above. However, it is not actually ideal, as it is primarily focused on maximizing tension on the IT band. That means that it’s about as good as you can get for pulling on the tensor fasciae latae muscle as well … but it will only partially achieve the goal of mobilization of the hips. For the gluteus medius and minimus, you need to be more specific.
Unfortunately, just as with the iliotibial band and the gluteus maximus and tensor fasciae latae muscles, it is not easy to elongate the gluteus medius and minimus muscles. They are primarily abductors of the hip, so hip adduction has the “running into the other leg” problem.
However, the gluteus medius and minimus are always hip rotators: that is, they grab onto the femur and “spin” it in its socket. And rotation is something we can do with the femur more easily. The following mobilization isn’t a perfect solution, but it’s probably the best there is — a “one stop shop” for all your hip muscle stretching/mobilizing needs. It also has the added benefit of being quite a pleasant stretch. There are only a handful of stretches and mobilizations that I ever bother with personally, and this is one of them.
Deep Gluteal Mobilization — Starting from a seated position, place your ankle on the stretch side over your knee on the other side. Let your lifted knee relax downwards for a moment, and then begin to lean forward from your pelvis. Avoid simply slumping forward, which is useless. Visualize pushing your belly button between your legs. Now do this on the other side, to even yourself out, even if you have symptoms only on one side. Now, to complete the mobilization for both sides, place your feet widely on the floor, and drop your knees straight down towards the floor.
GO TO TOP • CONTENTS • NOTES
Soft knee straps with velcro closures, to be worn just above the knee,188 are often recommended for iliotibial band syndrome — like an extremely minimal soft brace. Let’s do this one Q&A style. Reader Karen McCullough bought the book before I’d added this section. She wrote in to ask:
After reading your tutorial, I thought the strap idea was probably crap. But another health care professional just told me that she’d done some research, and that the idea behind the strap was to loosen the iliotibial band on the pad of fat tissue by tightening the ITBS right above it. What do you think?
I’m such a debunker that I usually don’t have much nice to say about products like this, and that’s probably why Karen thought it was “probably crap” after reading this tutorial. And that’s usually a safe guess!
But in fact I think the strap has potential — just definitely not for the biomechanical reasons usually given. I’ve seen many such rationalizations for these products, so it’s worth addressing here; clearly there is some confusion about just what exactly this product is supposed to do. Even the people who sell them tend not to understand why they might actually work. Whatever the mechanism of action might be, I am quite confident it is not mechanical in any sense. The answer Karen got was incorrect in my opinion, in at least two ways:
- Straps for ITBS are not tight enough to have any significant effect on the tough iliotibial band or the powerful and complex action of the knee. They are soft and secured only with a velcro patch. They are not designed to be worn tightly. Since the iliotibial band is not only extremely strong, but also flush with the thigh, it would require a very tight strap to have any effect on its shape, position, or movement — so tight that it would be like a tourniquet, and you would quickly turn blue below the knee!
- The idea that pressing on the iliotibial band proximal to the lateral epicondyle can somehow relieve pressure on the fat pad is quite strange. Imagine a tight watch strap. How will pressing on it in one spot relieve pressure anywhere else along its length? It just doesn’t work. No, if anything, quite the opposite would happen: press on any part of the iliotibial band, and you are increasing the tension on it (albeit very slightly), just as pressing on any part of a bow string will increase the tension along the length of the entire bow string. As you can see in my (rather lame) diagram to the right, putting a tight strap above the bulge of the knee is only going to increase the impingement of the fat pad.
It’s always about sensation
Despite the implausibility of a mechanical effect, there is decent (albeit indirect) evidence that a strap can help. If so, how is it doing it?
All joint function depends on complex sensory input and motor output equations. Exactly how we use our knee depends heavily on how our knee feels. The “feeling” of knee use is based on the “6th sense” of proprioception (see Proprioception, the True Sixth Sense), and involves a great deal of that sensory data.
Wearing the strap alters proprioception in the knee which often seems to have a benefit for any kind of knee pain, including iliotibial band syndrome. This has been suggested by some experimental results.189190191192
All kinds of therapeutic taping products — like the colourful tapes that were so popular at the 2012 Summer Olympics — probably exploit the same principle. To the extent that they work, they probably work for the same reason. But they do not work to a great extent: according to the British Journal of Sports Medicine, “Kinesio taping does not appear to have a beneficial effect on pain when compared with sham treatment,”193 which isn’t encouraging for IT band syndrome. For a more detailed review of taping and its cousins, see The Dubious Science of Kinesiology Tape.
Anecdotally, I have seen some signs that the strap is helpful, although your mileage will definitely vary. Some people get absolutely no results from it, while others seem quite strongly affected. But remember, this is a cheap and easy and risk-free intervention … which means that if there is the slightest evidence that it works, it is firmly in the “worth a shot” category of treatments! There is really no reason not to try it.
I recommend that you drop in on FootSmart.com and pick their Pro-Tec Iliotibial Band strap for just $15 (USD). “One size fits most,” and they have a 120-day satisfaction guarantee, so you can return it if it doesn’t do the trick for you.
But there are many different types of straps, and in general I would recommend more robust versions — wider, tougher straps. If you’re going to tinker with how the knee feels, tinker more. In fact, I think probably there’s a strong case to be made for a full soft brace...
A more complete neoprene sleeve for the knee is also an option — just not one that IT band patients seem to favour. It’s not “popular” like the straps, which I guess are cheaper and easier and have a bit of gimmicky mystique.194 But a soft brace is just a boring old brace! Ho hum. ITBS doesn’t seem like a knee condition that needs stabilizing, so it’s usually not on the radar.
Here’s the thing though: if it works, it probably works on the same principle as taping/strapping, only more so. If a strap “comforts” the joint, makes it feel different and a little safer, then a soft-brace probably does that same thing better.
A soft brace also probably has some genuine biomechanical effect, because — unlike the strap — it’s large and stiff enough to actually start to physically tinker with the equation of IT band and knee function. And where there is change there is hope.
A brace might even mimic and support some of the function of the IT band itself. As previously discussed, the IT band has a dynamic lateral stabilization role, tightening and loosening as needed to support (brace!) the ligaments on the side of the knee. Adding a bit of a “dumb” neoprene reinforcement might be quite useful: it might persuade your nervous system that there’s less work for your IT band to do.
I’m speculating, obviously, because there’s little else one can do on this sub-topic. But personally, if I am ever stricken by another case of ITBS, I’d definitely try a soft-brace — not a “gimmicky” little scrap of tape or a thin strap.
Hard bracing seems like a bad idea for ITBS
A reader asked about a treatment idea I’ve never heard of before: “Can the use of a knee brace locked at 20º be useful?” He was referring to using a hard brace, the kind of mechanical contrivance designed to strongly limit movement.
Definitely not recommended! But I get why it was of interest, and it’s worth explaining why it’s not such a great idea.
Immobilization is a rather extreme form of “rest.” In fact, it’s so extreme that it’s more likely to just be a new source of stress. Good quality “rest” in a rehab context is an absence of stressors. Eliminating most movement and loading is restful, but completely immobilizing the knee is likely just irritating. The human body does not seem to like immobilization, even for short periods.
Hard bracing is only useful in rehab when the alternative is dangerous instability, as with a serious fracture — but even in those cases it’s often surprisingly ineffective, either less effective at actually reducing motion and/or less necessary than we hope. Doctors avoid hard casts whenever possible these days. There’s even legitimate controversy and uncertainty about whether bracing severe spinal injuries is worthwhile — something I learned entirely too much about when my wife broke her back rather badly in 2010.
GO TO TOP • CONTENTS • NOTES
The value of shoe design and orthotics has always been exaggerated… mainly by the sellers of shoes and orthotics. Just a coincidence, I’m sure. It has always been much too easy to sell the idea of a foot “upgrade” for a moderate price point, which hits a nice sweet spot: expensive enough to impress (“they must be good if they cost $200!”) but not completely unaffordable. Evidence concerning the efficacy of orthotics for treating any lower leg problems has always been minimal and sketchy,195 and that’s where they seem most likely to be relevant; their effectiveness higher up (back pain) is even sketchier.196
For orthotics to make a difference, several things have to fall into place:
- You must have a diagnosable biomechanical problem, probably something terribly obvious, because if anything more subtle is going on, you’ll probably get different diagnoses from different professionals.
- The diagnosed problem must be relevant to IT band syndrome. This has to be a shot in the dark in the case of IT band syndrome, because it’s not clearly caused by any known biomechanical problem.
- The problem must be correctable by propping up parts of the foot, at least in principle. Quite a few problems simply cannot be fixed by orthotics. It depends on the problem.
- Assuming all of the above work out, you will still need to actually get the correct prescription, and properly.
That all adds up to a long shot, a long chain of reasoning where all of the links are weak but the whole thing is pointless if one of them breaks.
And yet orthotics may still be worth trying — particularly if you do have an obvious biomechanical problem. Good orthotics are a way to tinker with any gait or postural dysfunction that may have contributed to your pain in the first place. For instance, unusually high arches are a plausible factor in runner’s knee.197
My own example: orthotics that helped plantar fasciitis (but not IT band syndrome)
Orthotics seemed like a good option for me, because I have an obvious biomechanical problem in my right foot.198 Surely that gimpy turned-out leg made me more vulnerable to IT band syndrome?
No, not as far as I’ve ever been able to tell: my own IT band syndrome was always quite symmetrical, never much better or worse on either side, with or without orthotics.
But it was worth trying. The orthotics did help my chronic low-grade plantar fasciitis in that foot, and the experiment was fairly safe and cheap (compared to, say, a year of chiropractic adjustments). So why not?
What could go wrong?
Orthotics can be difficult to adjust to, disrupting fine-tuned postural adaptations and forcing awkward new ones. Some people find the cure to be worse than the disease. I don’t recommend trying orthotics during nasty phases of IT band syndrome when a backfire could be the most harmful.
On the other hand, it is during nasty phases when good results might be the most obvious — so you could try orthotics, but just quickly drop them if they cause any trouble. It’s generally safer to experiment with orthotics when the worst pain is over, the risk of aggravation is lower, and you’re getting into the rehabilitation phase of recovery and starting to exercise more and more.
Another caveat: it’s important to get orthotics from a reputable supplier (because there are a lot of disreputable ones), and certified pedorthists are probably the best choice (though a bit obscure, I’m afraid). You should be cautious of purchasing orthotics from physiotherapists, chiropractors, and even podiatrists.
For more information about orthotics, and how to shop for them, see Are Orthotics Worth It?.
GO TO TOP • CONTENTS • NOTES
Redundancy warning: this section is duplicated verbatim in all four of my tutorials about running overuse injuries. The point is pretty much the same regardless of the injury type being discussed.
The biggest fad in running since running itself is “natural running,” or running barefoot or in barely-there shoes (minimalist shoes). The idea is that humans are “born to run” and that running “au naturale” is healthier: lower risk of injury, and perhaps even a viable treatment for injuries you already have. For the whole backstory of the natural running fad, see Does barefoot running prevent injuries? I’ll focus on the evidence of injury relevance here.
As of early 2016, the best available evidence strongly suggests that barefoot running has no injury prevention benefit, let alone a treatment benefit. Details below.
(And don’t miss the brilliant sequel, Shit Runners Say To Barefoot Runners 2:48)
The first trace of real evidence on barefoot running
After a good decade of what amounted to nothing more than speculation about the benefits of barefooting, the first kinda, sorta direct evidence on the subject was finally published in the summer of 2012 (see Daoud et al). It suggested that barefoot running, or running with a forefoot strike, may reduce injuries.
It was not very good evidence, however: it came from a retrospective study of Harvard runners, showing that the forefoot strikers among them were less injury prone than their peers, based on medical records. This is not a great method. These runners could have been less injured for many other possible reasons. (For instance, they may have been the more cautious runners, using several strategies to minimize injury.) A study of this type (retrospective) just cannot prove a causal relationship, and that’s not just nitpickery: it really can’t.
The data is interesting, though. It’s like good circumstantial evidence in a court case — technically weak, uncertain by nature, but still emotionally persuasive.
And then better barefoot data happened
In 2016, Allison Altman and Irene Davis published the first prospective comparison of injury rates in shod versus barefoot running, in British Journal of Sports Medicine (see Altman).
“Prospective” is what we needed the whole time: follow a bunch of initially uninjured runners of both types to see what happens to their bodies. Only this kind of study is designed to actually answer the question. Although it wasn’t a perfect test, it was a huge improvement.
They studied more than 200 experienced runners over the course of a year: 94 wearing shoes, 107 with no shoes or (for about a quarter of their mileage) “true minimalist shoes.” The barefooters had been running that way for at least six months, and more than 18 on average (so they weren’t in that awkward transition phase where injury rates could well be higher).
The results are clear and unsurprising: there was no important difference in injury rates, just the types of injuries.
Each is better in some ways, worse in others. Although the paper emphasizes “fewer overall injuries” for barefoot runners, injury rates are what matters — the number of injuries per 1,000 miles, say — and they were “not statistically different between groups due to significantly less mileage run in the barefoot group.” That’s clearly bad news for the claimed benefits of barefoot running — full stop. (Although you might argue that it means that we don’t need expensive shoes, since barefoot is no worse.)
But there’s an extremely important caveat. And it does not flatter barefoot running.
The barefoot running volume was just 24 kilometres a week, while runners in shoes ran nearly twice as much — 41km — without an increase in injury rate. It’s safe to assume that the injury rate would be worse at a higher mileage than a lower one. Which means that the injury rate for barefoot running is probably the same as shod running at best.
Although this is all made clear in the paper, it’s strange that it wasn’t more strongly emphasized, because the implications are damning. As Alex Hutchinson put it for Runner’s World, “The only way the comparison has any relevance is if they’re arguing that barefoot running reduces injuries by preventing you from running as much as you’d like.”
A larger and longer study may have different results. And maybe there’s a real difference between minimally shod and true barefoot. That they mainly tested true barefoot running strikes me as the only real weakness in the study. (Minimalist shoes seem more relevant: true barefoot is never going to have large scale popularity.)
But this is an excellent start, and we can now say with high confidence that barefoot running is not a panacea for running injuries — and more and better data will probably, if anything, be even more embarrassing for the natural running fad’s claims of injury prevention.
Remember that most of our genetic predilections for behavior were shaped by the African savanna many thousands if not millions of years ago. So while “natural” in some sense, these predilections don’t necessarily serve us well today, since we live in a radically different environment. What happens in nature is a poor guide for making decisions anyway. One of the biggest boners in ethical philosophy is the naturalistic fallacy, which equates nature with “what’s right” and uses “what’s natural” to justify or excuse prejudice. We human beings are humane in part because we can look beyond our biology.
The violinist’s thumb, by Sam Kean
On running style and biomechanics in general
The nature of overuse injuries means that running style and biomechanics probably aren’t as important as the sheer amount of activity. I doubt that any running style, shoe, insert, or surface can change the forces on your joints enough to matter much one way or the other, relative to the overall training load. If you’re doing so much running that you’re going to injure your legs or feet sooner or later, no biomechanical advantage is going to do any more than slightly delay your fate.
It might do that. It might matter, a little. Of course it might. I also realize that many badass distance runners are pushing the envelope and interested in any sliver of a competitive edge. And very frustrated people with chronic pain are interested in any relief, even just a little. But small advantages and benefits are really hard to prove, and tinkering could just as easily backfire (this is not unusual with orthotics, for instance).
I have not gotten any reader reports of a “cure” by barefoot running, and I get a lot of reader reports from very serious runners. Even if I did I’d be all, “Okay, that’s nice. So?” Of course, you’re going to come across people who swear by these methods, but the only way to actually find out if something like a running technique or a shoe truly works in any way is to test them extremely thoroughly and carefully and science-ly, and perhaps with explosives, like the MythBusters … and most of those tests simply have not been done, and probably never will be done. Other than the 2016 paper testing barefoot running (Altman), we have virtually no real research about this stuff, and trying to guess if it works is like wondering if Guinness or Heineken makes you better at darts. Don’t be shocked by the lack of real science here — it’s entirely predictable.
There is a popular 2010 study by Lieberman et al about the biomechanics that has shown that “habitually barefoot endurance runners often land on the fore-foot before bringing down the heel” and “generate smaller collision forces than shod rear-foot strikers.” Daniel Lieberman is a smart guy, his research is interesting, and he interviews well. However, inferring injury prevention outcomes from his findings is pure guesswork. It’s so easy to see the words “smaller collision forces” and assume that it must be a good, injury-preventing thing. That is really just not a safe assumption, of course. For all we know, that smaller collision force (assuming it’s real) is coming at the expense of, say, much greater stresses on your calves and achilles to control the springier ankle action … which might protect against shin splints while sending achilles tendinitis rates through the roof. We don’t know that stuff, and we can’t know until thousands of runners have been carefully studied.
Biomechanics expert Benno Nigg on forefoot running: “It increases some forces and decreases others, mainly shifting the load to different structures,” from his book Biomechanics of Sport Shoes, well-described by Amby Burfoot for RunnersWorld.com. (That’s a great little read, and an excellent companion to this rant.)
If one part of your anatomy is in trouble, maybe there’s something to be said for shifting the load to other anatomy that is not currently injured. However, you also just end up with two injuries. “Shifting the load” isn’t going to eliminate stress on the original injury.
And, get a load of this: you can’t even get experts to agree that smashing the ground more softly is going to help something like, say, stress fracture — the one injury that seems to be particularly likely to be associated with higher impact! A 2011 review of thirteen papers on this topic was thoroughly inconclusive: “There is disagreement in the literature about whether the history of stress fractures is associated with ground reaction forces (either higher or lower than control), or with loading rates.” Translation: we literally cannot confirm that smashing the ground harder with your legs actually increases the risk of injuring them, and it might actually be exactly the other way around.
Do you really want to delve any deeper than that? Yeah, me neither. All that really matters here is that it’s obviously un-guessable, and yet that’s what everyone seems to be happy to do.
Given the shifting scientific analysis, runners are left with impassioned testimonials and heated debates.
from a nice little summary of this issue on Metafilter.com
If Vibram had any research supporting the health/running benefits of their FiveFingers product, I’m pretty dang sure they’d be shouting it out—but they aren’t. Their “health & wellness” page is barely longer than a haiku and offers only five incredibly broad bullet points of vague, meaningless, but nice-sounding things like “improve posture” and “move naturally” and (of course) “align the spine”—sure, it’s just like wearing a chiropractor on your foot! •eye-roll•
ChiRunning.com claims to teach a “revolutionary approach to effortless, injury-free running,” but if there’s any evidence for this claim on their website they seem to be hiding it. I couldn’t find even a half-hearted attempt to cite partially relevant research.
There are several other methods and many more products that have never been properly tested and would quite likely fail if they were. Somewhere in there, you could probably find stuff that helps, at least a little bit, but it is all literally impossible to know without testing. So I don’t waste a heck of a lot of energy on trying to figure out if these things work when the only way that it possibly can be figured out is not going to happen.
One final thought: the jarring forces of running may nevertheless have an impact on ITBS, despite the conflicting evidence and general unknowableness of it all. And so barefoot running and other strategies that minimize impact might make a difference, with minimal downside … and that’s key. In the next section, we’ll look in more detail at why road running might be a problem, and what to do about it.
GO TO TOP • CONTENTS • NOTES
When you do return to running, the drastic change to the fad of barefoot might not be the best option, and there are other ways of softening your run. For instance, seriously consider avoiding roads and sidewalks for a while. Hard-surface running seems to be more likely to cause or irritate iliotibial band syndrome than running on trails or treadmills.
Not that trails can’t be a problem too! It depends on the trail: one with hills could be a real problem, because more time descending is definitely a risk factor for ITBS. This is a distinct difference from other running injuries where ascent and descent is nowhere near as much of a factor. The runner with ITBS who tries to get away from running on pavement by switching to hilly trail running has clearly gone from frying pan to fire (but a runner with plantar fasciitis or shin splints would be fine).
Roads and sidewalks may also pose a risk to runners with ITBS that runners with other injuries don’t need to worry about. Hard-surface running is not necessarily terrible for runners in general — more below — but whatever the risk it’s easily avoided, and a risk that might be greater for ITBS.
So what is it about pavement and iliotibial band syndrome in particular? It might not be the rigidity of the surface, but the shape of it.
Running unevenly: slants and curves on that nice paved surface
Pavement running often involves a consistently uneven surface: sidewalks on an angle, or a road camber (the curved profile of the road). While it may seem obvious that running on a slant must pose some kind of problem, we should not accept this conclusion unquestioningly: maybe it is, and maybe it isn’t! The claim is made frequently, but rarely with any support or clear rationale that I have seen. Often it is based only on the assumption that leg-length differences are significant, and that running on a slanted surface is like having a leg-length difference — which is a reasonable assumption, but hardly a safe one.
There is just a little bit of direct evidence supporting a connection between crowned roads and ITBS, but only just barely enough to be worth a footnote.199 It’s just too specific a concern to have gotten much research attention.
Anecdotally, runners sure do report problems with slanted surfaces! Consider this reader comment:
The 2007 San Diego marathon had a new course. For about 10 kilometres of the race, we were on a steeply slanted highway. Although I had no pain at the time, the slant was a really noticeable strain, and my troubles definitely began after this race. Lots of runners were walking that section, saying that it just wasn’t worth it. Afterwards, the race organizers got tons of complaints about the course.
Arkady H., experienced Los Angeles marathoner trying to beat ITBS before beginning US Navy SEAL training
Or this one:
Just a bit of personal anectodal evidence that might be useful for you: The first time I got IT band syndrome was down in LA when I ran barefoot on the beach. Obviously the beach was cambered towards the water. I recall it vividly. I ran with the water on the right side and I started getting pain on the outside of my right knee. The rest of the weekend I could barely walk.
G Chung, runner and cyclist with intermittent knee pain for 20 years
Why would road camber be a problem for ITBS specifically? One theory is that the hip muscles (abductors) have to work harder when you’re on an angle, which exhausts them and makes them weaker, and “weaks hips” is one of the biomechanical bogeyman that supposedly causes ITBS. Despite the weakness of the weak hips theory, hip abductor weakness/exhaustion is associated with iliotibial band syndrome — covered in the hip strengthening section — so there is a plausible connection here. When we step down to one side, our gravitational centre in the pelvis wants to keep going sideways, and the gluteus medius and minimus muscles on the sides of the hips must work to stop that momentum.200 The same hip muscles also have extra work to do on the high side of the body: they need to swing the leg up and out. Running on a slant, we have to do both of these things over and over and over and over and over, so clearly there is the potential for this to drain the hip abductors of all vitality, triggering … whatever problem they allegedly cause for the iliotibial band at the knee (which is not clear).
Another theory is that the demand for lateral stabilization of the knee on impact — a function of the IT band, discussed more just below — is greater on a slanted surface, because the low-side knee has to be more protected from buckling outwards on impact than it would on a flat surface. This may be a factor regardless of whether or not you’re running off kilter, which is part of the next topic.
Maybe roads are just hard and that sucks for any lower body injury
Occam’s razor says the smart money is always on the simplest explanations, all other things being equal. And for sure the simplest explanation for why road running is hard on ITBS is that pounding on a rigid surface is a bit of a strain on everything, especially from the low-back down, and something has to give … and sometimes the point of failure/irritation is the side of your knee. Running on hard surfaces probably isn’t as much of a risk factor for injuries as everyone assumes, but the evidence does lean that way.201
As just mentioned, the IT band is partly like a built-in knee brace. It adds some “adjustable” support to the ligaments on the side of the knee: tension increases when stabilization is required, and decreases when mobility is required.202 A related shock absorption feature, “muscle tuning,” dynamically dampens impact vibrations with precisely timed muscle contractions — a very clever system.203 When running on a hard surface, the demands for changes in stability/mobility are more rapid and extreme: every impact presumably requires a spike in IT band tension. More tuning, more stabilizing!
And there’s another shock absorbing system: adjusting the springiness of our entire body. Harder surface? More bending! Softer surface? Less bending!204 It’s obvious in an extreme example, like bouncing on a trampoline, where you can actually keep your knees straight; but jump down just one metre onto concrete, and you’ll have to bend your knees quite a lot. What people don’t realize is that we’re amazing at making much finer, faster adjustments to springiness when running.205
I hope you haven’t been bored by all the setup above, because these shock-absorbing tricks are pretty cool. But here’s the real pay-off …
The amount of bending may be directly relevant to IT band syndrome. And if it is, so is the surface hardness.
As discussed above, ITBS is probably aggravated by a slower pace and/or repeated movement of the knee through a specific range of motion. Running on hard surfaces almost certainly requires more knee flexion… which may take the knee through exactly the most uncomfortable range of motion in an extremely consistent, problematic way. By running on springier surfaces, you give the knee less to do — and maybe specifically less of constantly swinging through the hurty part of your range of motion. It’s well worth trying.
Put a literal spring in your step
As an alternative to running on a springier surface, you could also try running on springs.
Modern running shoes with all their methods of cushioning do not do much to prevent common running injuries.206 They claim to absorb shock in all kinds of ways, but they aren’t springy. A spring gives energy back to you: it compresses, and then forcefully expands. Most shoes are mushy: they are made of foam, and foams absorb energy but don’t give much back. Running on foam is like landing on a trampoline that goes down but not up: it can’t toss you back up in the air. Ironically, there is some evidence that the mushy shock absorption of most running shoes might actually increase knee stresses — perhaps because they are actually interfering with the spring-like function of the arch, increasing the demand on other joints.207208
But there is one type of shoe that is designed to simulate running on springier surfaces, and that strikes me as being much more likely to make a difference for IT band patients. OESH Shoes (for women only) are a good example, and there are others based on springs. These shoes are inspired directly by something we definitely know about adapting to surface rigidity: we bend less when the surface bends more. And maybe shoes with springs can do some of the work for you.209
Whether or not that translates into preventing or treating ITBS or not is an open question, and likely to remain open. The effectiveness of spring-loaded shoes at actually preventing (or treating) injury is — of course — untested, unproven, and impossible to prove without a large trial that may never happen. Also, claims of injury prevention rarely pan out, and a cynic would bet against it for sure. Nevertheless, I am foolishly optimistic about this: I actually think there’s a better-than-average chance that these kinds of shoes actually do reduce injury-causing forces more than other shoes, and you can try them with less risk and radical departure from normal shoes than minimal/barefoot running, and with lower costs compared to any number of popular therapies. For the desperate ITBS patient, it seems well worth experimenting with. It may be speculative, but that’s what we’re here for: science-based guessing that nudges the odds in favour of a cure.
Impact reduction take-home points
Stay off concrete as much as possible. Prefer tracks and treadmills for the bounciest of all options, the best at giving you some of your impact energy back and reducing the load on your biomechanical spring. (Grass, sand, and chip trails are much softer than pavement, but are more like running on foam: mushy, not springy.) Do beware of hilly trails though, of course.
I work just a couple blocks from a running track. I don’t usually walk there, because I’d far rather stick to tree-lined streets and parks. But if my IT band flared up, I’d absolutely make walking on that track part of my rehab regimen, because that surface is obviously springier than anything else I can walk on regularly. Not everyone has such a convenient option, of course, but it’s an instructive idea.
- Try sprung shoes. If you can’t run on a springier surface, then try shoes based on springs, like OESH Shoes. Failing that, at least keep your regular running shoes fresh — the EVA foam in the midsole breaks down,210 and the biomechanics of running do shift in response. It probably does not matter a lot, but there’s also no need to take the risk.211 Although we’ve established that any non-spring shock absorption (mostly foam) is fundamentally different and probably not very helpful, if I run on foam I at least want it to be fresh foam!
- Run more gently. Avoid that jarring feeling! Experiment with your running style; do anything that feels less like you’re slamming your feet down. We can definitely run more softly if we try to,212 most easily by shifting to a forefoot impact and basically running more like a tiptoeing cartoon thief; barefoot running or minimal shoes help with this, as they strongly discourage heel impact and so we shift our impact to the forefoot. But there are trade-offs, as discussed above! Alternatively, another strategy for running softer is probably less prone to dicey trade-offs: slow down and take smaller steps! Basically just run less aggressively, period.
GO TO TOP • CONTENTS • NOTES
At the end of the previous chapter, I recommended running slower, with a lower cadence: slower, smaller steps. This is good advice for the broad goal of running more softly, but it is directly contradicted by something more specific that we know about ITBS: it seems to be irritated by running slowly!
Speeding up may seem like odd advice, but it’s actually one of the best specific recommendations I can offer to you: it’s quite likely to help, and it’s grounded in some simple but good science. The biomechanics were discussed above (in the section Running pace and IT band syndrome). But the idea is simple: the iliotibial band presses harder on the side of the knee when you run slowly than it does when you run fast. Therefore, when you train, do not slow down. Slower is not better in this situation. Less running is wise, but not slower running.
Some runners discover this simply by experimenting. Franklin Swann was fortunate to figure it out immediately, on his way home from the run that gave him his first ITBS pain:
As I was limping home, I decided to start experimenting. I found that if I took my normal short stride the pain came back very quickly. However, when I lengthened my stride and increased my leg’s range of motion during each step, the pain subsided considerably. Since your tutorial states that irritation occurs most at 30 degrees, I found it very interesting that the pain subsided when I increased my leg’s range of motion. I went from only being able to run 30 steps or so, to eventually running over a mile home with very little discomfort.
Franklin Swann, Dallas, Texas (3:30 marathoner, running seriously since about 2004)
By increasing his stride, Franklin spent less time in the relatively small part of the joint’s range that was the most painful, and more time in the other parts of the range.
An analogy: suppose you have a door with a squeaky hinge. It only squeaks when it’s between 25˚ and 35˚ open. Place the door in middle of that range and then slowly move it back and forth within that tiny arc — you get lots of squeaking, right? Now, instead imagine quickly opening and closing the door most or all the way, swinging rapidly between 0˚ and 90˚. It will still squeak, but a lot less — just a little squeak each time as you pass through the squeaky part of the range.
So try running with a longer stride, and see what happens.
And now, for a fun and (only slightly) relevant observation from a Muppet:
Less is not more. More is more!
GO TO TOP • CONTENTS • NOTES
The idea that leg-length difference (LLD) is clinically important is mostly seen in discussions of back pain. Runner’s knee is one of the few non-back-pain topics where leg length also comes up, but few runners have an obvious leg length difference. So the question is not so much “Do leg length differences matter?” as “Do subtle leg length differences matter? For people who use their legs intensely?”
In the context of back pain, the idea of the harmful LLD was first challenged long ago by Grundy in an important 1986 paper published in the British journal Lancet, showing that “Chronic back pain is … unlikely to be part of the short-leg syndrome.” A connection has been both supported and refuted by other researchers ever since, remains controversial,213 and the truth is probably in the middle as usual: maybe it’s a factor, but probably not a strong one for most people. There are more influential factors in back pain. There may well be in knee pain too.
A really weird/neat thing about LLDs is that they are often amazingly hard to measure and confirm, because the concept of “leg length” isn’t as easy to define as you might think. It’s dynamic. There are different types of LLDs. There are oddities like people who have a slightly longer thigh on one side, but a slightly shorter shin on the other, thus their knees are not at exactly the same level, but their overall leg length is the same.
Every diagnosis of an LLD by a therapist must be taken with a grain of salt. Clinical opinions on this topic are notoriously unreliable.214
Obviously a big enough leg length difference is going to be a problem. Dramatic leg length differences are rare, but someone who needs a 2-inch shoe lift on one side inevitably suffers from all kinds of related trouble, even with the lift. Their biomechanics are so distorted that there’s going to be long-term consequences no matter what.
It stands to reason that less dramatic differences might also be problematic, just less so — consequences that are less severe and more delayed. It also seems logical that a subtler vulnerability is more of a problem for people who push their bodies harder. A small leg length difference might never trouble a non-runner, but it might be the seed of injury in someone who trains hard. All very reasonable seeming.
But always beware of common sense and so-called logic when it comes to the human body. It’s equally plausible that we are fantastically adaptable, and that subtle differences are dramatically easier to adapt to than larger ones. The decrease in risk with decreasing LLD might be exponential. And training volume might constitute the mechanism of adaptability rather than a vulnerability. Someone who runs a lot with a small difference in leg length may be facing an easy challenge that they simply blast through.
So we’re going to need some careful testing to resolve this … scientific evidence that is (predictably) nonexistent/inconclusive.215 So it’s just an unknown.
How about an anecdote then?
Just please remember how persuasive-yet-unreliable anecdotes are! Reader Doug Allison sent me this success story:
I have found the fix for my own ITBS and it was different than most of the advice I’ve seen on the web. I got better with a heel lift to fix what seemed like a significant leg length difference, and the relief has been lasting for several months now.
Foam rolling and stretching not only didn’t seem to help me, but made the pain worse. I diligently did my hip exercises to strengthen my glutes, especially my gluteus medius. But the pain continued. After a month, even a quick warm up round on the track was unbearable. I avoided running and stayed on the ibuprofen. Still, going down stairs always hurt and my wife would hear me groan in my sleep when I turned in bed.
I have slight scoliosis, which runs in the family, so I’m a little crooked. My internist used to pound on my shoulder (jokingly) trying to even me up. My left leg is roughly a half-inch shorter than my right. Nothing had worked so far so a heel lift was worth a shot. I had a pair of half sole off-the-shelf orthotics a podiatrist had given me a few years ago. I started wearing them in whatever shoes I happened to be wearing, and there was no more ITBS pain within a few days.
I had just a little trouble when I started running again, but then I was fine. After several weeks of running three times per week with no more the odd twinge, I ran a 5K and won my age group (60-64) and had no problems with my feet or legs.
So there you have it: a pretty clean case study of a case of ITBS that cleared up when a substantial leg length difference was trivially corrected with a little lift (and note that the lift was probably not as large as the half-inch difference). Obviously it’s possible that he just lucked out, and his case backed off naturally, or for other reasons, at the same time he was trying to correct the LLD. But it’s also possible it actually worked.
GO TO TOP • CONTENTS • NOTES
Once in a while I hear from a reader who acquired their IT band syndrome from skiing, usually downhill. Skiing may have the same effect on IT band syndrome as hiking down mountains does; I hear about it less, but skiing is also a lot less common than hiking.
It also might be less of a problem: when knee pain strikes, you can sure get off the mountain quicker! Hikers can have some nasty experiences when they develop knee pain far from the trailhead; skiers can just do one last painful run and call it a day.
There are a few unique rehab considerations with skiing, and that’s the focus of this short chapter.
All-or-nothing: the load management challenge for skiers
It’s a highly seasonal activity and a bit all-or-nothing in character. Most people do nothing biomechanically like it, and then, boom, suddenly you’re doing it for whole days at a time: a large and rapid increase in knee loading that is nearly impossible to prepare for.
Because of the costs of skiing in both dollars and time, it’s hard not to overdo it right away, an extreme form of weekend warriorism that becomes more problematic with age and/or chronic injury. When a lower tolerance for overuse collides with a lot of use, you’re going to have trouble every time.
The rehab trick for skiers is probably to figure out how to ease your way into skiing each year, and probably accept an overall reduction in load.
Skiers can prepare for winter by do some preparation in the gym, squats and then loaded squats, trying to simulate the knee loading involved in skiing. But that won’t be perfect. Skiing is tricky to train for: lots of unusual physical stresses.
The main goal will be to limit your skiing time initially. That is, actually plan to go out and ski for less time… which will feel like a painful waste of time and money, an entirely pragmatic frustration. Going to the mountain just for a little bit of skiing before prudently withdrawing will not seem like an attractive option. For many people, it will seem downright unaffordable.
But partial days of skiing may be the only way to finally work your way up to a full day of skiing that doesn’t wreck you for the rest of the season.
I am not a skier (despite living near Whistler), so it’s a little tougher for me to write about this topic. If you have experience with any kind of skiing and IT band syndrome, I’d love to hear your story, questions, and concerns.
GO TO TOP • CONTENTS • NOTES
Regenerative medicine is the idea of replacing damaged or missing tissue by growing it from biological scratch — very sci-fi! This approach to medicine has genuine promise in the long-term, and it’s a fascinating and probably an inevitable innovation. It’s inspired by real biology, as exemplified in the salamander, the only vertebrate capable of complex re-growth of entire body parts — and that’s why the salamander is the mascot/logo/symbol for my work on PainScience.com.
So we know it’s possible. This is a trick that Nature has up her sleeve. And it’s very cool.
Unfortunately, all current regenerative medicine options so far are overhyped, experimental, and so biologically primitive that the salamanders would surely laugh at us (if they weren’t busy trying not to go extinct). Current regenerative therapies have been rushed to market, with all the hijinks that implies: sketchy experimental medicine at best, fraudulent profiteering at worst. These treatments would be in my “hall of shame,” but they’re a little too interesting and complex, with too much of a seed of truth, to dismiss in a paragraph or two. Dubious as regenerative therapies still are in 2022, they deserve their own chapter.
The main regenerative therapies for musculoskeletal and pain medicine all involve injecting or surgically implanting cells. They are:
- cartilage regeneration with autologous chondrocyte implantation — Not really relevant to ITBS (but perhaps very relevant to the other runners’ knee, patellofemoral pain).
- platelet-rich plasma — This is the one that ITBS patients are most like to encounter. It is widely touted for musculoskeletal conditions, especially repetitive strain injuries.
- stem cell therapy — A more generic, poorly defined type of regenerative therapy, mostly marketed to people with more dire medical conditions than runners’ knee.
“Prolotherapy” is also now notably touted as a “regenerative” therapy, but that’s just a silly attempt to breathe new life into an old brand. It’s a provocation therapy: injecting an irritant, which allegedly stimulates tissue growth. That “stimulates regrowth” part has been spun as “regeneration,” but it’s really a reach, and in this book it is relegated to the Hall of Treatment Shame.
Cartilage regeneration with “autologous chondrocyte implantation”
No one really suspects decaying cartilage of being the cause of IT band syndrome. ACI is focused on restoring frayed and pitted cartilage to its formerly smooth, shiny, youthful self. It’s probably the most promising of the regenerative therapies, and it’s an interesting topic — here’s my full article on it — but it’s also almost entirely irrelevant to ITBS. Moving on, then.
Platelet-rich plasma is very weak sauce
Give blood … to yourself?
Platelet-rich plasma (PRP) injections bathe troubled cells in a concentrated mixture of platelets from your own blood. Platelets are involved in clotting and wound healing, and so the more-is-better hope is that they’ll stimulate healing “naturally” — regenerative medicine, supposedly. Unfortunately, the hype and costs are high, there could be risks above and beyond the basic risks of any injection, and the science so far is completely discouraging — three major evidence reviews have ruled it “ineffective.” Although it’s plausible and interesting in theory, this stuff just can’t beat placebos in fair tests.
There is no PRP research specifically for IT band pain. Not one trial. That said, it’s the one option here that I can understand people wanting to try. If you’d like the details about PRP hype and bad news, see Does Platelet-Rich Plasma Injection Work? An interesting treatment idea for arthritis, tendinopathy, muscle strain and more
Stem cell therapy
Stem cells are generic cells that do not yet have a job. In theory, they can become what we need them to be, a potentially godlike medical tool. For contrast, PRP is just a cell therapy, not a stem cell therapy. Stem cell therapy is more generic and more serious, more truly “regenerative,” and much more promising than PRP in the long run — maybe, fingers crossed.
Meanwhile, it’s an extreme case of caveat emptor: stem cell therapy clinics have sprung up everywhere and they are way ahead of the science. This medical tech is just not safe and proven yet, and many of the clinics selling it are just cashing in on hype and hope. Regulation (American) of stem cell clinics is “something of a dumpster fire,” writes Jann Bellamy, a medical law expert.216 There are serious risks of wasting your money at the very least, and serious medical risks from shoddy practices as well.217
The stem cell therapy evidence is mixed, of course, but most of the promising evidence is coming from trials with a high risk of bias (studies conducted by people selling the treatment). For osteoarthritis (the best studied use of stem cell therapy), the British Journal of Sports Medicine says “we do not recommend stem cell therapy.”218 If it’s not good enough for osteoarthritis yet, it’s probably not going to be good for IT band pain either. Not in its current form, anyway.
Indeed, it’s well worth asking: what exactly are stem cells supposed to turn into to help people with a condition like ITBS? That is unclear! Throwing stem cells at some seriously irritated tissue is kind of like showing up at a gunfight with … some raw materials with which you could, in theory, craft yourself a gun.
GO TO TOP • CONTENTS • NOTES
Iliotibial band syndrome has a talent for lying dormant until your next big hike or run — you can go for months or even years thinking you’ve got it licked, only to find out the hard way that it’s still dogging you. This is, of course, based entirely on anecdotal evidence, including my own experience with the condition. The generally minimal research about ITB syndrome doesn’t even glance at how much the condition tends to recur or how to stop it. So this final section is just educated guessing, based on all of the above.
The trick, I think, is simply to be wary of assuming that it’s gone. This is easy at first. Anyone who’s had stubborn iliotibial band syndrome will just naturally take a long time to trust their knees again! But as my favourite Vancouver author wrote in the (excellent) novel Microserfs, human beings are “amnesia machines” — and sooner or later you will start to forget that you ever had such exasperating knee problems, and you’ll let your guard down. This, of course, is when it may bite you again.
Prevention notes for hikers …
For hikers, I strongly recommend climbing a smaller mountain before your first big hike in a while. This is a good check-in to see how your knees are doing. Iliotibial band syndrome seems to flare up — both originally and in recurrence mode — more readily in response to spikes in training or exertion. Knees that have a chance to adapt to increases in intensity are probably less likely to get cranky.
Also, after having my own “grizzly” experience with iliotibial band syndrome, I cannot say enough in favour of using hiking poles as a long term preventative measure of ITB syndrome as well as other knee problems. Every hiker knows that coming down is really much harder on the lower body in every way than going up. Poles really help with this.219 As one advocate writes, “I used to think that trekking poles were for posers. Now I swear by them.” Another serious hiker describes his experience with poles on a 30-mile trip:
I started out on the Wonderland Trail with a full, soft knee brace on my bad knee and it worked great. I should have worn one on the other knee since it decided to crap out after 30 miles. And I know that I would not have been able to do the trip at all if I did not use poles. Have you ever heard of the Wonderland Trail? On day 2 of Wonderland I thought about making a t-shirt that said “WEST COAST TRAIL IS FOR SISSIES.”
Chris Warke, Victoria, Canada
Prevention notes for runners and cyclists …
Serious runners and cyclists, of course, will train rationally and progressively for any event if they want to do well and remain injury free. My advice is to include — permanently — your favourite preventative measures for iliotibial band syndrome in your training: a life sentence. Perpetual vigilance! But I do not think this needs to be arduous or even particularly zealous. Just do enough to minimize the chances of trouble, and enough that you keep tuned in to the state of your knee, so that you are more likely to spot a recurrence sooner rather than later, the better to increase your preventative measures.
Virtually any of the self-treatment recommendations presented in the sections above will do, although I think that certain techniques are especially suited to long-term prevention:
- In the weeks leading up to an event, roll around on the floor on a tennis ball, working on trigger points in your hip muscles. It’s good for your hips regardless.
- The Iliotibial Band Mobilization (described above, or click the link) is a great choice for the long haul. I often notice my knee acting up a bit when I do this exercise, even when I have not noticed it while running: in other words, it’s a good way of checking in.
- Tactical icing seems a good option to me. Every time you feel that you’ve clearly pushed a bit, hit the side of your knee with a little ice, even if you have no symptoms. A sort of pre-emptive strike, a message to your knee: “Don’t even think about getting inflamed … ”
- Be wary of both old and new shoes. This is a simple, but powerful, preventative measure that doesn’t correspond to any of the self-treatment options above, as it is only relevant to the long term. Over the years, you will have many new shoes, and every worn-out pair and every new pair may create a stressful period of training for your lower legs. Don’t let shoes get too worn out, and when you get new ones do not keep training as if nothing has changed. Cut your distance or intensity for a while, and double your usual preventative measures.
While proof is a long way off, I think the best overall prevention method is maintaining good tissue health in the hips. Once you have recovered from iliotibial band syndrome, keep yourself as trigger-point free as possible around the hips with semi-regular massage therapy, self-massage, mobilizing, stretching, or yoga, and hopefully you will not be bothered by this condition ever again.
GO TO TOP • CONTENTS • NOTES
Here are some brief, skeptical notes on a few more treatments of dubious value. Anything in this section is, in my opinion, “possibly worth a shot, but probably not.” At worst, these bad boys are “100% guaranteed to be useless.” However, I won’t waste time discussing some of the silliest options. Amusingly, no matter how many treatment options I cover, there is always some joker out there who writes in to say, “How about aromatherapy? My cousin got aromatherapy for his IT band syndrome, and then he won the lottery and never had to worry about his knee ever again. Coincidence? I think not! Ergo, you should endorse aromatherapy in your evidence-based tutorial!” People are mighty peculiar.
Prolotherapy for ITBS is probably about 95% wishful thinking, with 5% vague possibility of clinical benefit. It was invented as a treatment for back pain about fifty years ago. It involves injecting substances that irritate tissues and force them to “toughen up.” It has always mainly been a provocation therapy, but lately it has been trying to jump on the regenerative medicine bandwagon. It has subsequently failed, in every fair scientific test, to show the slightest clear sign of efficacy for low back pain.220 The idea of toughening up tissues has such strong emotional appeal that it has been adopted for numerous other conditions, and it might actually be helpful for some of them.
However, it is not clear how prolotherapy would be of assistance for IT band syndrome, and it probably isn’t. Since the pain of IT band syndrome is probably primarily caused by tissue irritation, it is not clear how prolotherapy will help, since the intention of prolotherapy is to deliberately provoke (irritate!) tissue. Although you could concoct a rationale for doing so, it’s a debatable technique at best, rife with physiological uncertainties. And it has simply never been tested in any scientific experiment as of this writing. In other words, it’s a shot in the dark — extremely unlikely to be effective. It’s not even something that people claim works anecdotally. I’ve never heard anyone say “prolotherapy worked for my IT band syndrome,” despite receiving literally thousands of emails from IT band syndrome patients around the world.221 It’s included here because people ask about it, and not because anyone seems to think it actually works.
Active Release Techniques® (ART) is a popular kind of “deep tissue” (i.e. intense) massage that incorporates some movement. Done in the right way, ART has the potential to be effective for treating trigger points in the hip musculature, which might have some value. However, it’s more likely to be an imprecise substitute for more effective trigger point therapy. ART is based on an unclear therapeutic rationale, and practiced and marketed almost exclusively by chiropractors who want to incorporate some massage therapy into their practice. It is often intense and painful, and as such is frequently used on the IT band in much the same way, and with basically the same rationale, as the brutal scraping of Graston Technique® (debunked earlier). In short, ART is just strong massage of questionable quality and relevance to IT band syndrome.
Chiropractic therapy. Some kinds of chiropractors routinely recommend spinal adjustment for a wide variety of health problems, including any pain problem and any serious disease. This is the “big idea” of chiropractic, and it has been criticized by experts for a century, including several prominent chiropractors. These controversies are explored in my article The Chiropractic Controversies Some chiropractors try to rationalize the value of spinal adjustment for knee pain by arguing that “alignment” problems in the joints of the low back, hips, and knees may have consequences in the knees. A few even believe that adjustment of only the uppermost intervertebral joint in the neck is required to achieve therapeutic effects throughout the entire body. Even if such extraordinary causal relationships exist, they would be extremely subtle, idiosyncratic, hard to diagnose, and harder still to reliably treat. In short, the relevance of chiropractic therapy to IT band syndrome is implausible. Chiropractic adjustments are certainly not working any miracles for ITBS patients.
Acupuncture. Over the past several years, acupuncture has been steadily stripped of its former credibility as a pain treatment by one fair scientific test after another. The general theme has been that random needling — without regard for any of the principles of acupuncture — works exactly as well as real acupuncture, which is no better than placebo. Both real and faked acupuncture have a placebo effect, because people believe that needles are good medicine. For all the sordid details, please see my full analysis, Does Acupuncture Work for Pain? Acupuncture might have some potential to “accidentally” treat IT band pain insofar as the treatment overlaps with trigger point therapy for the gluteus maximus and tensor fasciae latae muscles. Treatment of trigger points is part of acupuncture, but is rarely its focus, and of course inserting needles is the only treatment method they use.
Nutraceuticals. There are several popular supplements that allegedly reduce inflammation and/or enhance athletic performance in a variety of ways. Glucosamine sulfate and chondroitin sulfate are particularly popular for knee pain. They are primarily supposed to be good for your cartilage — knees are quite cartilaginous places! — and many consumers confusedly assume these supplements are relevant to any knee problem, including IT band syndrome. However, these substances have recently failed to show any benefit even for standard knee osteoarthritis,222 let alone knee problems that have nothing to do with cartilage. Some of the nutraceuticals probably do have some interesting biological effects, and perhaps some anti-inflammatory action — for instance, there’s little doubt that bromelain does have at least some anti-inflammatory properties. It’s more a question of whether these substances are more effective or safer than existing anti-inflammatories — which is unproven and somewhat unlikely. It might be worth experimenting with a few of these options, but cautiously: there is a real danger of wasting your money. For much more information, see Vitamins, Minerals & Supplements for Pain & Healing
IT band plungering. No, really! If it’s stuck, suck it! In this poor quality video we see a physical therapist using a cute little toilet plunger — for a hobbit loo? — to “suck” the iliotibial band off the leg. To achieve an IT band “release”, of course! I think this is silly. Sure, it’s easy to see the suck-up-the-stuck-tissue “logic” of it, but it’s at odds with well-known IT band anatomy (the IT band is firmly anchored to the femur for most of it’s length), and it’s at odds with the nature of IT band syndrome (it doesn’t hurt because of “adherence of the IT band to the tissues beneath it,” as thoroughly covered earlier in the book). Even if the IT band did get stuck to underlying tissues, I’m not so sure that baby plunger would be helpful.223 This treatment idea is mostly just good for a chuckle. I’m sure it’s harmless to everything but your wallet … but also pointless. It boils down to a weird form of massage.
Homeopathic Arnica, such as T-Relief (formerly Traumeel), and other brands). Homeopathic (diluted) herbal ointments featuring Arnica are claimed to be good medicine for muscle pain, joint pain, sports injuries and bruises, but their effectiveness is questionable. Known to most customers as an “herbal” arnica cream, most actually contain only trace amounts — too little to be a chemically active ingredient. Homeopathy involves extreme dilution of ingredients, to the point of literally removing them. Some other herbal ingredients may be less diluted and more useful. However, neither homeopathic or pure herbal creams of this type have produced results better than placebo in good quality modern tests, for any condition.
IT band syndrome is just the sort of thing that people think this stuff might help: pain that seems to be just below the skin, where a medicinal cream seems to have a shot at working. However, I have never heard of a case of ITBS that responded to it. With serious chronic pain, it’s obvious if a new treatment makes a difference. If homoepathic arnica were working any miracles (or doing anything at all), I would have heard about it by now, repeatedly — even if I didn’t believe it, I would have heard about it. Is an absence of anecdotes evidence? No, but it does seem damning in a world where you can find testimonials for practically anything.
Homeopathy as a profession is rotten with dangerously irresponsible ideas, as shown in the BBC’s 2006 exposé of homeopaths in London recommending completely ineffective remedies to travellers in place of genuine anti-malarial medication,224 and numerous examples in 2020 of homeopaths claiming that they can prevent or treat COVID-19. Wikipedia has quite a good complete review of homeopathy.225 For more detailed information, see my article, Does Arnica Gel Work for Pain?
“I did _______ and that did the trick!”
When ITBS goes away, patients often attribute the recovery to something therapeutic that they’ve been up to, understandably. Most people reading this tutorial have chronic ITBS and have no such success story to tell. But you have probably heard plenty of stories like this from other victims! Or (better yet) you used to tell stories like that yourself, until you realized that your ITBS just kept coming back, even after you thought you’d whipped it!
Just as people like to recommend cold remedies, they like to recommend physiotherapy remedies.
The single most suspicious thing about these stories is that they can’t all be right. Like gods and religions, most of them are mutually exclusive, and the profusion of contradictory popular theories tends to undermine all of them. Invariably, the _______ is filled with something passed down from “on high” from a persuasive therapist, or something that we put some effort into and therefore we would like to believe we weren’t wasting our time. It sounds good, you worked at it, and the problem went away — ergo it was effective therapy. Right?
Perhaps, but probably not!
Many people who experience iliotibial band syndrome recover rapidly and never experience it again, or do so only erratically — the lucky bastards! Most cases are not chronic. Therefore, most cases will come and go, regardless of what you do or do not do therapeutically, creating the appearance of a cure where in fact there is only random or intermittent recovery.
I’ve experienced it myself. At least a couple times since my own original experience with slow-healing ITBS, I’ve had flare-ups that vanished without a trace — no special self-treatment effort required. So it’s not so much “random” to recover from ITBS quickly as it is simply the manifestation of many unknowable variables which make flare-ups appear random to the victim.
Someone may feel like they have a “gut feeling” that deep transverse friction massage was the thing that did the trick, and they might even be right … but guts cannot be trusted. Carl Sagan was once pressed by a reporter for a premature conclusion. When asked, “But what’s your gut feeling?” Sagan famously replied, “I try not to think with my gut.”
What would Carl Sagan do? Always a good question.
GO TO TOP • CONTENTS • NOTES
Sometimes readers get to this point and feel a bit puzzled: although they appreciate all the information, they’re not really sure what to do next. What is my advice, exactly? After all this analysis, after debunking so many popular ideas and treatments … well, what’s left? What should you do about your IT band syndrome? What are my actual recommendations? What’s the plan?
My advice is spelled out one treatment option at a time above, but it’s time to summarize. This section will focus on the positive — on planning, tactics, and “putting it all together” — and I mainly discuss only the options that I consider worth trying or at least considering. I generally lead with the options that have the best bang for buck and work down from there.
The invasive options deserve an early mention because most ITBS patients avoid scalpels and needles for longer than they need to; they should be considered more seriously and sooner for this condition than with a lot of other repetitive strain injuries. For instance, I am certainly not particularly enthusiastic about surgery for, say, plantar fasciitis (foot arch tendinitis). It’s not nearly as safe and reliable for that condition, in part because there are so many sub-types of plantar fasciitis — ITBS is quite consistent by comparison. And while steroid injections involve a real risk of highly problematic rupture in the arch, injecting the side of the knee for IT band pain is far safer. And surgery for IT band pain is about as attractive an option as elective surgeries get, especially for desperate runners. Most people have more fear of the invasive options than they need to have.
Nevertheless, it always makes sense to make sure you’ve tried a bunch of easier, safer, cheaper options first.
Especially actually, really, truly resting.
Yes, to a great extent, smart ITBS treatment really does boil down to a rest … but not just rest. Rest should be augmented by a number of other treatment efforts while you are resting:
- Consider 1–3 steroid injections while resting. It might be a great way to control pain and possibly help restore homeostasis at the same time that you’re greatly reducing knee stresses.
- Voltaren gel is a much more lightweight option than steroid injections, but also obviously much less potent.
- Regularly apply ice to the knee to stimulate the tissue without stressing it. Consider dialing it up and icing a lot (power icing, many short sessions), or even getting into contrast hydrotherapy for maximum exertionless tissue stimulation — a bit fussy for the knees compared to the feet, but do-able.
- Massage your hips, butt, and thighs. It probably won’t make much of a difference biomechanically, and you really can’t “elongate” the IT band, but it sure feels nice, and it may be useful to reduce stiffness and soreness in the region.
- Massage with movement, too: that is, mobilize. Work with the “deep gluteal mobilization” as much as you want.
- Strengthening for the hips — based on the shaky idea that weak hips are a cause of knee dysfunction — barely makes this list. But it does make the list because, particularly for frustrated runners, “stronger hips” are a perfectly agreeable side effect of the treatment — and, who knows, it might help. Note that strengthening for the quadriceps is pretty much out of the question while trying to rest the knees.
- Also just barely making the list: I think it’s worth trying a soft knee strap or some taping during the rest phase — not to correct any biomechanics, but just to tinker with knee sensations and neurology (because change is as good as a holiday). It’s yet another lightweight, non-curative option, but another one to pile on in the spirit of everything but the kitchen sink.
- Finally, regular ultrasound — one of the weakest of all mainstream physical therapies, but hey … it does vibrate tissue with sound, and you never know. Give a physical therapist a little money for a few treatments with an open and hopeful heart and, who knows, you might just get a boost from it.
- Be kind to your nervous system — do everything you can to dial down the drama surrounding pain and give your nervous system a rest (a creative and highly personal challenge to be sure). It’s a good idea regardless, but it’s critical if you suspect that you’ve become neurologically sensitized — feeling too much pain, too easily, out of proportion to any likely explanation — this is really important. It’s also probably the single best specific reason to massage: to constantly dose the leg with pleasant sensory input.
But mostly … just don’t irritate your knee.
Some people are disappointed by the unavoidable physiology of rest, particularly people who haven’t done it properly or don’t want to do it properly. One older athlete was quite angry with me when we discussed it. Paraphrasing his final thoughts on the matter:
I was angry because I know in my heart that I’m not actually willing to actually rest as much as I probably need to, and it pisses me off to realize what that means. It means I have to give up running, because I’m not willing to give up the other things that I do for long enough to save the running. Whatever. I’m old. I’ve had enough running.
Rest is the closest thing there is to an Answer — but I’m referring to resting much differently, more intensively and strategically, than most people imagine at first. In my experience, despite my best efforts to explain the importance of resting and how to do it properly, resting is the thing that almost everyone gets wrong. Nearly every case turns into a conversation about how to rest properly. What is resting properly? Three reminders:
- Resting properly means avoiding not only running or skiing or whatever main activity you wish you could be doing, but avoiding any other activities that might irritate your knee.
- Resting properly means strategically and carefully re-introducing the least knee-irritating activities first.
- Resting properly means knowing that four weeks may not be enough. You can’t rest for four weeks and then say “I tried resting, it didn’t work.” Tough cases may need three times that long.
What next after rest
What if “good” resting fails? What if it doesn’t make any significant difference? What if the pain barely budges, or still comes roaring back every time you head out for a run? Well, that’s when to take surgery seriously as an option. At that point, you have little to lose. There are other therapies you could try, but surgery is safe enough and good enough. Especially if you can find a surgeon willing to try the new procedure.
On the other hand, what if rest is working pretty well? In that case:
- Do more! Success gives people patience. If resting is working, many people are willing to invest more time in the effort and really be sure.
- And/or expand into treatment options that may start to challenge the knee a bit.
Some treatment and management ideas could easily sabotage resting because they stress the knee in some way. But as resting works its magic, the knee becomes less vulnerable, and these ideas can be introduced more safely and perhaps more productively:
- The best example is the complex IT band mobilization — a moving stretch — that I described. It can so powerfully strain the sore spot that it’s probably not a smart thing to do while you’re resting (especially in the early stages).
- If you’re a runner, as you return to running, control knee stress with small doses of running — obvious! — and do not run slowly — not so obvious. Generally tinkering with running style is fine (i.e. barefooting), but I don’t particulary recommend it.
- Walkers and runners may also get some knee protection from a pair of Oesh shoes (women only) or other leaf-spring shoes — the only kind of biomechanical tinkering I endorse (tentatively). Give it a try … but be alert for any backfiring.
- Friction massage has some modest but real potential, but at the same time it involves deliberate provocation of the hurtin’ tissue. So either it isn’t compatible with resting at all, or it’s best performed cautiously. If resting has already failed, though, it becomes a much more rational option.
- Walk and hike with poles! Particularly if you have a lot of hills to deal with as you return to normal. Or even stairs. Probably about half of knee pain patients should buy a pair of cheap hiking poles and generally use them quite a lot for several weeks.
- Once again barely making the list: strengthening, this time for the quadriceps in particular, and the rest of the legs generally. There’s very little reason to believe it will make a big difference … but it might, fitness is good, and you can cautiously start training the legs if the knee pain is easing with rest.
- If you’re still fighting pain long term, more serious opiate pain medications are not out of the question, though obviously you need to be cautious and manage the addiction risk carefully. However, they can be a valuable tool.
There are of course some other treatments I’ve described that more desperate patients could consider — but this is everything that’s reasonably promising in my opinion.
Good luck with your knees.
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 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 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 outruns 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:
- 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!
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 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 discovering that one of the t’ai chi 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 know many things that I really wish I had known when I first hurt myself! And that’s why this very, very long tutorial exists.
Contradiction Addendum: So do I think stretching is pointless or effective? Sharp-eyed readers will notice a contradiction: I’ve written many things about stretching in general, and stretching for ITBS especially, that sound like I think it’s pointless. And yet I have also credited it with seeming to contribute to my own recovery, and I still actually recommend trying it. What gives? What is it, thumbs up or down?
For my most positive take on ITB stretching, basically I’m grading on a curve 😜 and assuming good technique (which is rare). It’s also cheap, easy, plausible, and safe enough to be worth a shot. And my own personal experience has some weight (not much, but some). These factors upgrade what would otherwise be a negative opinion up to a “cautiously optimistic” one.
Paying in your own (non-USD) currency is always cheaper! My prices are set slightly lower than current exchange rates, but most cards charge extra for conversion.
Example: as a Canadian, if I pay $19.95 USD, my credit card converts it at a high rate and charges me $26.58 CAD. But if I select Canadian dollars here, I pay only $24.95 CAD.
Why so different? If you pay in United States dollars (USD), your credit card will convert the USD price to your card’s native currency, but the card companies often charge too much for conversion — it’s a way for them to make a little extra money, of course. So I offer my customers prices converted at slightly better than the current rate.
refund at any time, in a week or a year
call 778-968-0930 for purchase help
return to introduction
return to discussion of hiking
GO TO TOP • CONTENTS • NOTES
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.
Thanks to every reader, client, and book customer for your curiosity, your faith, and your feedback and suggestions, and your stories most of all — without you, all of this would be impossible and pointless.
Writers go on and on about how grateful they are for the support they had while writing one measly book, but this website is actually a much bigger project than a book. PainScience.com was originally created in my so-called “spare time” with a lot of assistance from family and friends (see the origin story). Thanks to my wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless useful chats, repeatedly saving my ass, plus actually building many of the nifty features of this website.
Special thanks to some professionals and experts who have been particularly inspiring and/or directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Mark Crislip, Scott Gavura, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Lars Avemarie, PT, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, James Fell, Dr. Ravensara Travillian, Dr. Neil O’Connell, Dr. Tony Ingram, Dr. Jim Eubanks, Kira Stoops, Dr. Bronnie Thompson, Dr. James Coyne, Alex Hutchinson, Dr. David Colquhoun, Bas Asselbergs … and almost certainly a dozen more I am embarrassed to have neglected.
I work “alone,” but not really, thanks to all these people.
I have some relationship with everyone named above, but there are also many experts who have influenced me that I am not privileged to know personally. Some of the most notable are: Drs. Lorimer Moseley, David Butler, Gordon Waddell, Robert Sapolsky, Brad Schoenfeld, Edzard Ernst, Jan Dommerholt, Simon Singh, Ben Goldacre, Atul Gawande, and Nikolai Boguduk.
Warm thanks also to reader John J, who reported more typografic errors and other miner glitches in onelarge batch than I would ever have Dramed posssible so many years into the the lyfe of this documint. Many readers have helped out with such reporting, but John’s effort was truly remarkable.
GO TO TOP • CONTENTS • NOTES
This document was originally published as a much simpler article in 2002, based on keeping notes I’d been keeping on the topic since my own experience with ITBS in the late 90s. It was then expanded and republished as a book-length tutorial in April of 2007, and has been updated and revised regularly since then. An unusually large batch of improvements were made in 2012 in preparation for recording an audiobook.
Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document 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 132 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).
Jun 11, 2022 — Small improvement: Added some useful reader perspective on their experiences asking surgeons for assistance. [Updated section: The new surgery: excision of tissue from under the IT band.]
Feb 12, 2022 — Minor improvement: Added significantly more information about proximal tibiofibular joint injury. Not many readers need it, but it will be helpful for those who do. [Updated section: Other possible diagnoses and sources of diagnostic confusion.]
Jun 25, 2021 — New section: No notes. Just a new chapter. [Updated section: A “dysfunctional” tensor fascia latae: one of the classic usual suspects.]
Nov 14, 2020 — Minor edit: Modernized the homeopathic arnica section. [Updated section: The treatment hall of shame.]
Nov 14, 2020 — New chapter: No notes. Just a new chapter. [Updated section: Regenerative medicine? Mainly platelet-rich plasma injections.]
Nov 10, 2020 — Science update: Added a scrap of new data about hips tiring faster in ITBS patients, useful mostly as an example of inconclusive research — but we try to work with what we have. [Updated section: Hip strengthening is badly over-hyped.]
Nov 10, 2020 — Science update: Added citations to evidence that NSAIDs may actually impair healing. [Updated section: Ibuprofen and friends: non-steroidal anti-inflammatory drugs (NSAIDs), especially Voltaren® Gel.]
Jul 10, 2020 — New chapter: No notes. Just a new chapter. [Updated section: Duck-footing it — an odd tactic for avoiding aggravation.]
Jun 6, 2020 — Major science update: Updated the discussion of inflammation with an important new subsection, “The other side of the story: don’t count inflammation out quite yet,” based mainly on the fascinating research of Dakin (among others). [Updated section: Where’s the fire? The inflammation myth.]
May 11, 2020 — New chapter: No notes. Just a new chapter. [Updated section: CASE STUDY: A runner finally rests, for the win.]
May 11, 2020 — Correction and editing: I removed a digression because it was based on an error about the relationship between stride rate and running speed. And I did some general editing while I was here. [Updated section: Why does IT band pain gets so nasty so fast? A vicious cycle related to running pace.]
Jan 14, 2020 — New sub-topic: Compared and contrasted oral and injected corticosteroids; added some colour/context about anabolic steroids. [Updated section: Steroid injections: a complicated mix of certain risks and uncertain rewards.]
Jan 6, 2020 — New chapter: No notes. Just a new chapter. [Updated section: Some considerations for skiing.]
Jan 6, 2020 — Added sub-topic: Expanded the scope of the section to include soft and hard bracing as well as taping and strapping. [Updated section: Knee taping, strapping, and bracing for IT band syndrome.]
Dec 9, 2019 — Major upgrade: Much clearer and more thorough integration of greater trochanteric pain syndrome. [Updated section: Hip and thigh pain: part of the problem, or a red herring?]
Aug 27, 2019 — New section: No notes. Just a new chapter. [Updated section: Runner’s knee without running: post-surgical lateral knee pain.]
Aug 12, 2019 — Minor improvement: Added more detailed explanation of testing popliteal tendon. [Updated section: Other possible diagnoses and sources of diagnostic confusion.]
May 17, 2019 — New section: No notes. Just a new chapter. [Updated section: The noise, noise, noise! The significance of knee snaps, crackles, and pops.]
Mar 19, 2019 — Edited and expanded: Added a new basic concept to the introduction, added discussion and recommendations about total rest, and clarified several other points. [Updated section: The art of rest: the biggest challenge and opportunity for patients who have supposedly “tried everything”.]
Jan 4, 2019 — Science update: Added brief discussion of the poor state of evidence for stem cell therapy, citing Pas et al. [Updated section: Regenerative medicine? Mainly platelet-rich plasma injections.]
Archived updates — All updates, including 89 older updates, are listed on another page. ❐
GO TO TOP • CONTENTS • NOTES
- “Many people are afraid of running because between 30 to 70 percent (depending on how you measure it) of runners get injured every year.” And many of those are IT band syndrome cases. That quote is from a fascinating talk about the athletic toughness of human beings, Brains Plus Brawn, by Dr. Dan Lieberman, evolutionary biologist of “Born to Run” fame.
- The muscles that actually control the tension on the iliotibial band, such as the tensor fasciae latae and gluteus maximus.
Quadriceps strengthening is a standard treatment option for patellofemoral pain syndrome — another common overuse injury of the knee (more on this below). It doesn’t necessarily work even for that condition, or not for the reasons people think it does, but it is a nearly universal rehab choice for that condition, for better or worse. Not for ITBS, though! Although strengthening some muscles (hip and gluteals) has been proposed as a treatment for ITBS, and might work, quadriceps training has almost no relevance to ITBS. I assume that it gets prescribed anyway simply because these two knee pain conditions are often confused, even by pros who should know better — a simple case of mistaken identity.
Also, physical therapists just love to prescribe strength training. Like stretching, it’s is dogmatically included in most rehab, regardless of whether it actually makes any sense.
- As they are of most musculoskeletal problems. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt. See The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones.
Cartoon by Loren Fishman, HumoresqueCartoons.com
There’s nothing formal or authoritative I can cite to support this position; there is no international standards organization defining minor musculoskeletal injuries; IT band syndrome isn’t even in the Merck Manual (a famous medical dictionary) or the Medline/Merrian Webster medical dictionary.
All obscure definitions are somewhat arbitrary and a product of social concensus, and so my position is based on the definition used in most academic writing and research on the topic. My strong impression after many years of writing about ITBS is that discussions and articles that talk about IT band syndrome as anything but a lateral knee pain condition are mostly amateurish, with ignorance of the condition prominently on display.
- Ingraham. A Historical Perspective On Aches ‘n’ Pains: We are living in a golden age of pain science and musculoskeletal medicine … sorta. ❐ PainScience.com. 3066 words. We can put a man on the moon, but we can’t fix most chronic pain. The science and treatment of pain was neglected for decades while medicine had bigger fish to fry, and it remains a backwater to this day. The seemingly simpler “mechanical” problems of musculoskeletal health care have proven to be surprisingly weird and messy. The field is dominated by obsolete conventional wisdom and the speculations of desperate patients and opportunistic cure purveyors. Ignorance is widespread thanks to professional pride and tribalism, ideological momentum, screwed up incentives, and poor critical thinking skills. But the worst single offender? The pernicious oversimplification of treating the body too much like it’s a complex mechanical device that breaks down: (“structuralism”).
- As of 2021, only just over 350 search results in PubMed! Compare that to 7700 for frozen shoulder, or 11600 for carpal tunnel syndrome. Also, more so in the case of iliotibial band syndrome than other conditions, a great number of those papers are tutorials for professionals, not primary research. To an amazing degree, they all tend to repeat conventional wisdom and reference each other and clinical experience instead of original science.
- Ellis R, Hing W, Reid D. Iliotibial band friction syndrome — A systematic review. Man Ther. 2007. PubMed #17208506 ❐
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!
- In my own 3000 hours of training — three full years of nothing but studying aches and pains and how to treat them — ITBS was barely even mentioned. 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!
- This is not a joke. It’s an impressive-looking, conventional sports injury textbook — but its inadequate coverage of ITB syndrome is typical for the subject. The text is Clinical Guide to Sports Injuries.
- Grant HM, Tjoumakaris FP, Maltenfort MG, Freedman KB. Levels of Evidence in the Clinical Sports Medicine Literature: Are We Getting Better Over Time? Am J Sports Med. 2014 Apr;42(7):1738–1742. PubMed #24758781 ❐
Things may be getting better: “The emphasis on increasing levels of evidence to guide treatment decisions for sports medicine patients may be taking effect.” Fantastic news, if true! On the other hand, maybe I should be careful what I wish for, since my entire career is based on making some sense out of the hopeless mess that is sports and musculoskeletal medicine …
- Falvey EC, Clark RA, Franklyn-Miller A, et al. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scand J Med Sci Sports. 2010 Aug;20(4):580–7. PubMed #19706004 ❐ “Our results challenge the reasoning behind a number of accepted means of treating ITBS.”
- Sutker AN, Barber FA, Jackson DW, Pagliano JW. Iliotibial band syndrome in distance runners. Sports Med. 1985;2(6):447–451.
- 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. PubMed #10449021 ❐ PainSci #56967 ❐
In a study of 1300 US Marine Corp recruits in training, nearly 40% got hurt, and 78% of them got repetitive strain injuries, and those injuries tended to happen during the weeks with the most 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%), iliotibial band syndrome (5.3%), and stress fractures (4.0%) were the most common diagnoses.” The findings suggest that “[vigorous] training, particularly running, and abrupt increases in training volume may further contribute to injury risk.”
- 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 saw more iliotibial band syndrome in my decade of clinical 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’ — it was quite a lot.
- 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.
- Some papers that mention cycling: Ellis, Fairclough, Fredericson, Martens, Farrell.
- Linde F. Injuries in orienteering. Br J Sports Med. 1986;20(3):125–127.
From the abstract: “Medial shin pain, Achilles peritendinitis, peroneal tenosynovitis and iliotibial band friction syndrome were the most frequent overuse injuries [in 42 orienteers].”
- Sound ridiculous? Pokémon Go is one of the most successful video games in history, and the first super successful gamification of exercise: to play, you have to get outside and walk, run, or ride. In the summer of 2016, several tens of millions of players were out and about every month — which is actually similar to the number of recreational runners. Those stats have continued in 2017, with an estimated 65 million monthly active players.
- Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat. 2006 Mar;208(3):309–316. PubMed #16533314 ❐ PainSci #56738 ❐
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.
- Fairclough J, Hayashi K, Toumi H, et al. Is iliotibial band syndrome really a friction syndrome? Journal of Science & Medicine in Sport. 2007 Apr;10(2):74–76. PubMed #16996312 ❐
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.
The science of anatomy was slow to develop historically, and remains surprisingly half-arsed. One good example from 2015 is the somewhat embarrassing discovery of lymphatic vessels in the central nervous system. Oops, how’d we miss that?
My Heart Will Go On, by Robert Krulwich & Adam Cole, explores the goofiness of historical beliefs about anatomy, especially the heart. The influential Roman physician Galen made many declarations about human anatomy without ever doing a human dissection, and then no one else checked his work for another 1000 years, and so everyone thought that the liver was a pump just like the heart. Those crazy Romans! And everyone who trusted them for a millenium!
Don’t be too quick to laugh, though. Modern people still have many odd misconceptions about anatomy (albeit less glaring that “the liver is a pump”). The significance of anatomical variations is chronically underestimated by everyone but surgeons. And it’s amazing how many people swear by treatments with anatomically dubious or impossible premises. Such as wrong IT band anatomy! And the significance of variations is chronically underestimated by everyone but surgeons.
- Devan MR, Pescatello LS, Faghri P, Anderson J. A Prospective Study of Overuse Knee Injuries Among Female Athletes With Muscle Imbalances and Structural Abnormalities. J Athl Train. 2004;39:263–267. PubMed #15496997 ❐ PainSci #56601 ❐ For a more detailed analysis of this research, see IT Band & Patellofemoral Pain Defy Common Sense.
- Followed, predictably, by patellofemoral pain syndrome.
- I’ll cover this in more detail below, but basically there’s good evidence that the Obert test is not a good way to judge the tightness of IT bands (see Willett).
- Anyone who has felt that knows exactly what I mean, but the sensation eludes many people, because it’s difficult to apply enough tension to the IT band to achieve it. Many people will simply never feel it. More about this in the stretching section.
- More detail: most tendons could be snipped at either end and then tied in a bow. They are mostly disconnected from other tissues, except at the ends where they are attached to muscle and bone. In contrast, the iliotibial band is simply a massive thickened section of the sausage wrapping of connective tissue that surrounds the whole thigh.
- Eng CM, Arnold AS, Lieberman DE, Biewener AA. The capacity of the human iliotibial band to store elastic energy during running. J Biomech. 2015 Sep;48(12):3341–8. PubMed #26162548 ❐ This paper presents the abstract and speculative “results” of a thought experiment aided by a fancy model of the leg, so it can’t be taken too seriously, and in particular it has no clear clinical implications. But it is interesting! Mostly it purports to show that the IT band stores elastic energy, much like the achilles tendon, just a lot less: “1J of energy per stride during slow running and 7J during fast running,” which is “approximately 14% of the energy stored in the Achilles tendon at a comparable speed.” If that’s how it actually works, it’s a handy biological adaptation that makes running a little more efficient: more evidence that we are “born to run.”
- Vieira EL, Vieira EA, da Silva RT, et al. An anatomic study of the iliotibial tract. Arthroscopy. 2007;23(3):269–274.
- Putzer D, Haselbacher M, Hörmann R, Klima G, Nogler M. The deep layer of the tractus iliotibialis and its relevance when using the direct anterior approach in total hip arthroplasty: a cadaver study. Arch Orthop Trauma Surg. 2017 Dec;137(12):1755–1760. PubMed #29032422 ❐ PainSci #53147 ❐
- How is this possible? Fairclough et al explain that “our cadaveric dissections confirm that the ITB is simply a thickened, lateral part of the fascia lata. It completely surrounds the thigh, is anchored to the femoral shaft by the lateral intermuscular septum.” In general, muscle sheaths are no more free to move relative to the muscle they contain than a sausage wrapper is free to move relative to the sausage. In this case, the wrapping is even stronger, because it actually penetrates to the bone, attaching to the femur along most of the length of the femur (on the linea aspera). This was backed up by another dissection study in 2009, which also found that the IT band is “uniformly” and “firmly” attached to the thigh bone, “from greater trochanter up to and including the lateral femoral condyle” — in other words, the full length of the thigh. This thing does not slide around.
- As the knee bends, tension on the IT band shifts from the front to the back. That is, it “pops out” a bit, first a little ahead of the knee, then further back — which can look an awful lot like movement. But it’s just parallel fibres tightening in sequence, like a wave, as the knee changes position. Other tendons actually do slide around and snap over other structures, but the IT band is not free to do this.
- Although this has been contradicted by other evidence — Jelsing 2013 — for now I’m working with the assumption that any movement is probably trivial and not a sliding at all, like the slight swaying of seaweed anchored to rocks in shallow water. That is, it’s not “rubbing” back and forth so much as flexing to and fro.
I often hear athletes, trainers, and therapists talking about the anatomy of injuries with great ignorance and confidence — a nasty combination. They believe pain is coming from a part of them that literally doesn’t exist, or not in that neck of their woods.
Many lesser-trained professionals make so many mistakes that it’s clear that they could not pass an anatomy exam … like the massage therapist I saw once who tried to base his treatment of me on a completely imaginary muscle — a weird hybrid of two or three others, like the quadriglutator or the sternobiceptoid. (I would have laughed, if he hadn’t been carelessly handling my fairly badly injured shoulder at the time, trying to find my … whatever he thought he was looking for.) It may sound absurd, but we live in a world where some people believe that ketchup is a vegetable — and anatomy is much harder than food classification. It’s one thing to be wrong, but the overconfidence of these anatomical fantasies really tickles my funny bone.
- Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat. 2006 Mar;208(3):309–316. PubMed #16533314 ❐ PainSci #56738 ❐ From the abstract: “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.”
- Muhle C, Ahn JM, Yeh L, et al. Iliotibial band friction syndrome: MR imaging findings in 16 patients and MR arthrographic study of six cadaveric knees. Radiology. 1999;212(1):103–110.
From the abstract: “MR imaging accurately depicts the compartmentlike distribution of signal intensity abnormalities in patients with ITBFS.”
- Nemeth WC, Sanders BL. The lateral synovial recess of the knee: anatomy and role in chronic Iliotibial band friction syndrome. Arthroscopy. 1996;12(5):574–580.
- Michels F, Jambou S, Allard M, et al. An arthroscopic technique to treat the iliotibial band syndrome. Knee Surg Sports Traumatol Arthrosc. 2009 Nov 5;17(3):233–236. PubMed #18985317 ❐ PainSci #56117 ❐
Iliotibial band syndrome (ITBS) is an overuse injury mainly affecting runners. The initial treatment is conservative. Only in recalcitrant cases surgery is indicated. Several open techniques have been described. The purpose of this study is to evaluate the results of a standardized arthroscopic technique for treatment of a resistant ITBS. Thirty-six athletes with a resistant ITBS were treated with a standardized arthroscopic technique, limited to the resection of lateral synovial recess. Thirty-three patients were available for follow-up (mean 2 years 4 months). Thirty-two patients (34 knees) had good or excellent results. All patients went back to sports after 3 months. In two patients a meniscal lesion was found, which required treatment. One patient with only a fair result had associated cartilage lesions of the femoral condyle. Our results show that arthroscopic treatment of resistant ITBS is a valid option with a consistently good outcome. In addition, this arthroscopic approach allows excluding or treating other intra-articular pathology.
- It’s not really inflammation, actually. But we’ll come back to that point below in the section The inflammation myth. Think of it as just “irritation” for now.
- In past versions of the tutorial, I called it this and ended up with readers trying to find the “fat” on the side of their knee! Such is the power of the word “fat,” I guess. Please note: there is no palpable pad of fat.
- Hariri S, Savidge ET, Reinold MM, Zachazewski J, Gill TJ. Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: indications, technique, and clinical outcomes. Am J Sports Med. 2009 Jul;37(7):1417–24. PubMed #19286912 ❐
- Prepatellar bursitis usually follows a good whack on the knee, and causes an obvious, weird swelling that makes your kneecap look “fat.” Because it is common, and because it affects the kneecap, it is mistaken for patellofemoral pain syndrome. However, occasionally I’ve seen a badly wrong diagnosis of ITB syndrome for this straightforward condition.
- Trochanteric bursitis is a hip pain, and can only be diagnosed as ITBS by professionals who are unaware that ITBS is knee pain by definition. Unfortunately, due the widespread myth that ITBS involves pain anywhere along the IT band, this misdiagnosis is quite common.
- I don’t believe IT band texture, as palpated (felt) by a professional, which can only be subjectively judged, is a particularly meaningful or reliable indicator of anything. In my experience, tissue texture correlates poorly with pretty much everything that it supposedly correlates with. (See You’re Really Tight for more about that.) So, for instance, you can have people with nasty IT band syndrome and lovely pliable-seeming IT bands, and vice versa, which kind of throws a monkey wrench into the theory that the texture tells us anything that matters. It’s either a coincidence, and/or it’s at the mercy of such complex variables that us mere mortals cannot be expected to make anything of it. I’ve worked with scads of IT band clients, and I could never detect a clear correlation between the syndrome and IT band texture.
It is also notoriously easy for any of us to feel what we want or expect to feel. Without a way to objectively calibrate, it’s hard or impossible to know what to do with subtle observations like this.
- Willett GM, Keim SA, Shostrom VK, Lomneth CS. An Anatomic Investigation of the Ober Test. Am J Sports Med. 2016 Mar;44(3):696–701. PubMed #26755689 ❐ “The results of this study suggest that the Ober test assesses tightness of structures proximal to the hip joint, such as the gluteus medius and minimus muscles and the hip joint capsule, rather than the ITB.”
- If people with PFPS have truly tight IT bands, perhaps it would tell us something about ITBS? He asked hopefully? A 2009 study in Manual Therapy looked at this. In a (very) tiny study of just a dozen people with patellofemoral pain, the researchers found that the patients had “highly significant” IT band tightness compared to a dozen people without pain.
Seems like a smoking gun! Painful kneecaps, tight IT bands … slam dunk, right? But this study is almost microscopic, so the evidence is about as reliable as an ADHD dalmatian in a park full of squirrels. Study a different dozen, get a different answer! (And we already know that Devan did get a different answer.) But the real problem with it is just a logical glitch: if IT band tightness is a critical factor for both conditions, then ITBS and PFPS should go together like double and trouble. And yet that is definitely not standard, or even common. In particular, PFPS usually does not include the distinctive lateral hot spot of ITBS.
So this logical problem is a key to both conditions, and something just isn’t adding up: “tightness” is failing to be a meaningful metric in one condition, or the other, and probably both.
- Many doctors have reported that people with iliotibial band syndrome tend to have tight iliotibial bands, but it’s almost impossible to tell how reliable that information is: have they really made a good observation of many clients, or are they just repeating what they’ve heard other doctors say, who were repeating what other doctors said, ad infinitum? This happens in health care!
- Orchard JW, Fricker PA, Abud AT, Mason BR. Biomechanics of iliotibial band friction syndrome in runners. Am J Sports Med. 1996 May-Jun;24(3):375–379. PubMed #8734891 ❐ It’s a reasonable speculation, but please note that they didn’t actually prove this (or anything else) about running speed as a risk factor for ITBS: they didn’t do an experiment here. They simply looked at the anatomy and mechanics of knee movement in runners, and found that they “had an average knee flexion angle of 21.4 degrees,” which is somewhat less than the angle at which IT band presses hardest on the side of the knee (“the 30 degrees of flexion traditionally described in the literature.”) Extrapolating from this, they suggested that running downhill (and doing it more slowly) involves more knee flexion in the “danger zone” around 30˚ and therefore “adjustments to running gait that cause the knee to be in a more flexed position at footstrike may prevent ITBFS from occurring.”
- RunnersWorld.com [Internet]. Burfoot A. Could Usain Bolt Run from Paris to Beijing? And More on Short Strides; 2013 Oct 2 [cited 15 Aug 19].
- Even the strongest candidate risk factors for iliotibial band syndrome have never been confirmed by copious scientific research. For instance, Khaund writes: “Few studies have shown any direct relationship between biomechanical factors and the development of iliotibial band syndrome. Excessive pronation causing tibial internal rotation and increased stress in the iliotibial band was believed to be a factor in the development of iliotibial band syndrome; however, the literature does not support this theory.” In 2009, this opinion was echoed by Ferber et al: “No definitive answer can be put forth regarding potential running-related injury mechanisms and excessive foot pronation” (still, after many years of study).
- Lehr ME, Plisky PJ, Butler RJ, et al. Field-expedient screening and injury risk algorithm categories as predictors of noncontact lower extremity injury. Scand J Med Sci Sports. 2013 Aug;23(4):e225–32. PubMed #23517071 ❐
This looks like some positive evidence for the power of the FMS screen to predict injury. My money is still on the null, and I don’t think any of the other evidence to date is all that persuasive yet (because Whiteside et al).
But if, in the end, good evidence says the screen works, then bully for FMS! Almost all my gripes with FMS concern over-reaching its stated purpose as a screen and using it as a diagnostic/prescriptive tool. If it does actually work as a screen, I will be the first in line to say, “Congratulations, FMS!” But I’m not holding my breath.
(See more detailed commentary on this paper.)
- Whiteside D, Deneweth JM, Pohorence MA, et al. Grading the Functional Movement Screen™: A Comparison of Manual (Real-Time) and Objective Methods. J Strength Cond Res. 2014 Aug. PubMed #25162646 ❐
Is the Functional Movement Screen accurate? Who knows: “virtually no investigations have probed the accuracy of FMS grades assigned by a manual tester.” So Whiteside et al probed it! They compared “the FMS scores assigned by a certified FMS tester to those measured by an objective inertial-based motion capture system.” Alas for FMS, “agreement between the two grading methods were poor in all six FMS exercises.” They go on to argue that all FMS research so far may be a bit of a write-off, and everyone should probably just go back to the drawing board and try again.
(See more detailed commentary on this paper.)
- Ingraham. Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain. ❐ PainScience.com. 21878 words.
- Again, I’m not saying it isn’t possible, just difficult: a real top-of-class kind of challenge. I personally don’t claim to be able to do it. I know for a fact that I am not qualified to assess a running gait accurately. I don’t have those skills.
- Gokaleo.com [Internet]. Bouma S, Orwell S. Sorry, but Science Says Running is Good for You, Not Bad; 2013 Jun 13 [cited 13 Dec 11]. A thoughtful evisceration of Kiefer’s popular anti-running article, a case study in bad science writing that represents the trend of “anti-running claims making the rounds of the blogosphere lately.” According to Bouma and Orwell, Kiefer’s article is littered with unsupported claims, leaps of logic, and — above all — classic bogus citations (“a string of numbers after a claim does not automatically make it true”). It would be hard for anyone to take Keifer’s article seriously after reading this analysis!
- Williams PT. Effects of running and walking on osteoarthritis and hip replacement risk. Med Sci Sports Exerc. 2013 Jul;45(7):1292–7. PubMed #23377837 ❐
This analysis of about a zillion runners versus walkers found that “running significantly reduced arthritis and hip replacement risk”… but due in large part to the fact that runners were typically skinnier. So weight was a trump factor here.
This data flies in the face of the common assumption that running is much harder on the joints. Instead, what it clearly shows is that running is either neutral or helpful, and weight is a much more important factor regardless of whether you walk or run.
- There are several possibilities, most of which are based on the idea that you need to strengthen or toughen something. Many of these vigorous therapies simply pile on the knee stress.
- I used to be afflicted with horrendous insomnia, and I learned quite a bit about it before I was finally able to recover, and that is why I can use this analogy with confidence. It’s a very interesting topic, see my free tutorial: The Insomnia Guide
- Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008;466(7):1539–1554.
- Khan KM, Cook JL, Taunton JE, Bonar F. Overuse tendinosis, not tendinitis, part 1: a new paradigm for a difficult clinical problem (part 1). Phys Sportsmed. 2000;28(5):38–48. PubMed #20086639 ❐
From the abstract: “If physicians acknowledge that overuse tendinopathies are due to tendinosis, as distinct from tendinitis, they must modify patient management … ”
- Medzhitov R. Origin and physiological roles of inflammation. Nature. 2008 Jul;454(7203):428–35. PubMed #18650913 ❐
Medzhitov explains that “although infection-induced inflammation is vital, it might be a special case.” Indeed, classic inflammation seems to be an oddball, and has relatively little in common with lots of other “inflammation” — the immune response to infection is dramatic and conspicuous, but perhaps exceptional and distinctive within the broader context of the biology of healing and adaptation … which is so diverse that it really doesn’t fit comfortably under one umbrella term like “inflammation.”
- Dakin SG, Newton J, Martinez FO, et al. Chronic inflammation is a feature of Achilles tendinopathy and rupture. Br J Sports Med. 2017 Nov. PubMed #29118051 ❐
This paper now stands as the best available evidence so far that rumours of inflammation’s demise in tendinopathy are exaggerated/oversimplified. There are no other important sources I’m aware of so far (as of early 2020), and Dakin et al. cite only their own evidence on this.
- This awkward disclaimer is now working its way into my writing wherever trigger points are introduced. For many years I believed that trigger points were on firm scientific footing, but that is increasingly unclear. They are somewhat controversial after all, and some experts have correctly pointed out that they may not be what they seem to be: for instance, not actually a muscle problem. Nevertheless, it is possible to work with the concept of trigger points while the debate continues about what’s really going on. Please consider the term “trigger point” to be a shorthand for a complex, unexplained and possibly illusory phenomenon (and perhaps you did already).
- Kim C, Nevitt MC, Niu J, et al. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ. 2015;351:h5983. PubMed #26631296 ❐ PainSci #53332 ❐
This analysis of thousands of patients confirmed a jarring disconnect between signs of arthritis on hip x-rays and hip pain: “Hip pain was not present in many hips with radiographic osteoarthritis, and many hips with pain did not show radiographic hip osteoarthritis.” What they mean by “many” is “practically all”: roughly 80% of patients with signs of arthritis had no pain, and at least 85% of patients with hip pain had no sign of arthritis! These numbers held up even at the extremes — most older patients with a high suspicion of hip arthritis did not in fact have arthritis that could be diagnosed with an x-ray.
- I’ve even seen it described as a “friction” syndrome — the IT band rubbing on the greater trochanter — in much the same way it is much more often described as a friction syndrome of the knee. There are several problems with this, but mainly it’s just that it’s only one of a lot of possible causes of hip pain, and quite a speculative one at that. “Friction” probably isn’t the problem at the knee, and it’s probably not the problem at the hip either.
- And muscular trigger points are so common throughout the general population — virtually universal — that it is impossible to even say whether or not they are more common, or worse, in ITBS sufferers. Certainly there is no scientific evidence of this. However, it does seem likely, and that is my clinical experience.
- Because almost all referred pain is distal to its origin. That is, when pain spreads, it tends to spread down and out. Hip pain often spreads down to the knee, but knee pain rarely or never spreads upwards to the hip — not by the mechanism of referred pain anyway.
- The mechanism of injury for ITBS is so clearly mainly overuse, whereas hip pain has many possible causes — including a gimpy knee and the awkward and uneven gait it probably causes.
- Jelsing EJ, Finnoff JT, Cheville AL, Levy BA, Smith J. Sonographic evaluation of the iliotibial band at the lateral femoral epicondyle: does the iliotibial band move? J Ultrasound Med. 2013 Jul;32(7):1199–206. PubMed #23804342 ❐ PainSci #53484 ❐
OBJECTIVES: The purpose of this study was to determine whether the iliotibial band (ITB) moves relative to the lateral femoral epicondyle (LFE) as a function of knee flexion in both non-weight-bearing and weight-bearing positions in asymptomatic recreational runners.
METHODS: Five male and 15 female asymptomatic recreational runners (10-30 miles/wk) aged 18 to 40 years were examined with sonography to assess the distance between the anterior fibers of the ITB and the LFE in full extension, 30° of knee flexion, and 45° of knee flexion. Measurements were obtained on both knees in the supine (non-weight-bearing) and standing (weight-bearing) positions.
RESULTS: The distance between the anterior fibers of the ITB and the LFE decreased significantly from full extension to 45° of knee flexion in both supine (0.38-cm average decrease; P < .001) and standing (0.71-cm average decrease; P < .001) positions. These changes reflect posterior translation of the ITB during the 0° to 45° flexion arc of motion in both the supine and standing positions.
CONCLUSIONS: Sonographic evaluation of the ITB in our study population clearly revealed anteroposterior motion of the ITB relative to the LFE during knee flexion-extension. Our results indicate that the ITB does in fact move relative to the femur during the functional ranges of knee motion. Future investigations examining ITB motion in symptomatic populations may provide further insight into the pathophysiologic mechanisms of ITB syndrome and facilitate the development of more effective treatment strategies.
- They did “check,” but it was only a cursory check. According to Jelsing et al., they mostly confirmed a lack of translational movement just by “visually inspecting a highly defined athlete’s knee.”
- In standing subjects. It was quite a bit less when they were lying down, but that probably isn’t as relevant to iliotibial band syndrome. Although .7cm may not seem like much movement, it’s probably more than enough for the idea of an IT band that rubs on the side of the knee. However, that still doesn’t mean that friction is actually occurring — more on this below.
- Maybe not enough knees, mostly all from the same kinds of patients; they didn’t measure in a single-leg standing (which would simulate the stance phase of running better); they didn’t control for the positions of other joints.
- “Additional participants were not examined because of the difficulty in identifying the actual posterior margin of the ITB and differentiating it from the fascia with which it blends.”
Even though “dysfunctional buttocks” is actually a popular idea, well-known as “dead butt syndrome.” Gluteal amnesia. Glutes not “firing” or “activating.” “Uneven” or “underactive” glute contraction. And so on. But is it causally linked to IT band syndrome? By anyone? Nope, basically no one ever — it is not a thing that even gets floated. Even though they are literally linked!
The inconsistency is glaring. There’s really no logical reason to suspect that a dysfunctional TFL is a cause of ITBS, but not a dysfunctional gluteus maximus. It should be both, or neither. It’s fishy that it’s just one.
- Note that this topic also overlaps significantly with the more general idea of that hip weakness causes leg injuries, which I have written a lot about below: it’s actually one of the longest chapters in this book. I could have added this sub-topic to it and made it even longer. But “weakness” is only one way of defining the TFL’s alleged dysfunctionality, so I thought I’d give it a chapter of its very own.
- Besomi M, Maclachlan L, Mellor R, Vicenzino B, Hodges PW. Tensor Fascia Latae Muscle Structure and Activation in Individuals With Lower Limb Musculoskeletal Conditions: A Systematic Review and Meta-Analysis. Sports Med. 2020 Jan. PubMed #31898217 ❐
The conditions studied were IT band syndrome, greater trochanteric pain syndrome, patellofemoral pain, as already mentioned, plus also hip joint arthritis and knee ligament tears.
This is a reference to the “streetlight effect,” an observational bias that is a classic and chronic clinical error: paying attention only to that which is easy to pay attention to, measure, and see. The name comes from an old metaphor about a drunk who is foolishly looking for his lost keys only where the light is good, under the streetlight rather than where he actually suspects he lost them.
Yeah, it’s not a very good joke. But the metaphor has stuck.
- Baker RL, Souza RB, Rauh MJ, Fredericson M, Rosenthal MD. Differences in Knee and Hip Adduction and Hip Muscle Activation in Runners With and Without Iliotibial Band Syndrome. PM R. 2018 10;10(10):1032–1039. PubMed #29705166 ❐
This tiny study identified a tiny difference in the activation of the tensor fascia latae muscle, and a tiny difference in adduction, in runners with IT band syndrome — all of which has only a tiny chance of having any clinical or even etiological meaning in the absence of more and better data, from research actually designed to explore the topic. It’s probably just a bit of noise in the data. Even if the signal was clearer, good luck interpreting it.
It’s not a bad study or paper, but it is trivial. To the authors’ credit, they wrote: “We advise caution using these findings to support treatments intended to modify tensor fasciae latae activation…” It they hadn’t said it, I would have!
- General practitioners tend to confuse this knee injury with other knee problems (and give questionable and extremely basic advice even when they do recognize it). Physical therapists are exposed to ITBS more often (people often take sports injuries directly to a physical therapist), and they are better at diagnosing it … but still not good enough, I’m afraid.
- Could there be some exceptions to this? Perhaps, but rare. I can imagine a scenario where an impact on the lateral epicondyle starts a case of ITB syndrome suddenly. Or an ITB that is on the verge of flaring up could be pushed over suddenly by a violent contraction of the core muscles, perhaps because of a fall. But these are clearly unusual scenarios.
- Pain on the front of the knee, around or under the kneecap, or on the inside of the knee, is simply in the wrong place. A bad case of iliotibial band syndrome might have symptoms so intense that they extend to include the front of the knee, but the pain will never be just on the front, and it’s simply flat out impossible for the inside of the knee to hurt due to iliotibial band syndrome. No, it’ll definitely be on the side, with the most tender spot located at about the level of the top of the kneecap.
- Sutker AN, Barber FA, Jackson DW, Pagliano JW. Iliotibial band syndrome in distance runners. Sports Med. 1985;2(6):447–451. “Most athletes had been running 20 to 40 miles a week for one year or longer and had significantly changed their distance, speed, terrain, surface, and/or shoes before the onset of symptoms.”
- Ekman EF, Pope T, Martin DF, Curl WW. Magnetic resonance imaging of iliotibial band syndrome. Am J Sports Med. 1994;22(6):851–854.
From the abstract: “ … magnetic resonance imaging demonstrates objective evidence of iliotibial band syndrome and can be helpful when a definitive diagnosis is essential.”
- Muhle C, Ahn JM, Yeh L, et al. Iliotibial band friction syndrome: MR imaging findings in 16 patients and MR arthrographic study of six cadaveric knees. Radiology. 1999;212(1):103–110.
From the abstract: “MR imaging accurately depicts the compartmentlike distribution of signal intensity abnormalities in patients with ITBFS.”
- Costa ML, Marshall T, Donell ST, Phillips H. Knee synovial cyst presenting as iliotibial band friction syndrome. Knee. 2004;11(3):247–248.
- Orchard JW, Fricker PA, Abud AT, Mason BR. Biomechanics of iliotibial band friction syndrome in runners. Am J Sports Med. 1996 May-Jun;24(3):375–379. PubMed #8734891 ❐
Orchard et al proposed that “sprinting and faster running on level ground are less likely to cause or aggravate iliotibial band friction syndrome because, at footstrike, the knee is flexed beyond the angles at which friction occurs.” It’s a reasonable speculation, but please note that they didn’t actually prove that running speed is a risk factor for ITBS: they didn’t do an experiment here. They simply looked at the anatomy and mechanics of knee movement in runners, and found that they “had an average knee flexion angle of 21.4 degrees,” which is somewhat less than the angle at which IT band presses hardest on the side of the knee (“the 30 degrees of flexion traditionally described in the literature.”) Extrapolating from this, they suggested that running downhill (and doing it more slowly) involves more knee flexion in the “danger zone” around 30˚ and therefore “adjustments to running gait that cause the knee to be in a more flexed position at footstrike may prevent ITBFS from occurring.”Of course, this model of descent pain at least partly depends on assuming that ITBS is a friction syndrome, an assumption that has since been seriously called into question by Fairclough.
- Like patellofemoral syndrome, for instance. PFPS and ITBS are the usual suspects for ascent and descent pain, respectively.
- Muhle C, Ahn JM, Yeh L, et al. Iliotibial band friction syndrome: MR imaging findings in 16 patients and MR arthrographic study of six cadaveric knees. Radiology. 1999;212(1):103–110.
- Michels F, Jambou S, Allard M, et al. An arthroscopic technique to treat the iliotibial band syndrome. Knee Surg Sports Traumatol Arthrosc. 2009 Nov 5;17(3):233–236. PubMed #18985317 ❐ PainSci #56117 ❐
- Smith TO, Davies L, Donell ST. The reliability and validity of assessing medio-lateral patellar position: a systematic review. Man Ther. 2009 Aug;14(4):355––362. PubMed #18824392 ❐ They noted that this is not much evidence, and more is needed. No kidding! We’re talking about one of the most common of all testing procedures for knee pain, and we’ve only properly studied its accuracy on 306 knees, ever? Think about how many bazillions of dollars of therapy money is spent on knee alignment issues! Something is wrong with this picture.
- Of course it’s possible that there is a way to accurately assess patellar alignment, and maybe someday we’ll know that and all manual therapists will be properly trained in it. Maybe. But that doesn’t matter much to patients now. These scientific tests of existing methods with reasonably competent practitioners should have produced clear agreement and strong reliability — not “variable” results. That’s pretty discouraging for patients.
- The space behind the knee is the popliteal fossa. Several structures that pass through the popliteal fossa are named after it: the popliteal artery, the popliteus muscles, and so on.
In a normal seated position, with heels and feet firmly on the ground, turn your test foot outwards a bit. And then pull your heel into the ground, as though you want to swing your heel down and back, bending the knee more, but the ground is in the way. There’s basically no movement: you are just trying to move, pulling on knee tendons in a way that will be uncomfortable if your popliteus tendon is in trouble, but it shouldn’t bother your IT band.
This isn’t a foolproof test, though, because it’s a bit subtle and tricky. If the motion reproduces your symptoms, then popliteus tendinitis is a strong possibility; if it doesn’t, it’s less likely, but nothing is really proved or disproved.
- de Oliveira Silva D, Pazzinatto MF, Priore LB, et al. Knee crepitus is prevalent in women with patellofemoral pain, but is not related with function, physical activity and pain. Phys Ther Sport. 2018 Sep;33:7–11. PubMed #29890402 ❐
- The dominant theory of joint popping depends on the concept of “cavitation” — the rapid formation and explosive collapse of bubbles in a liquid due to pressure changes. It is almost certainly wrong or at least incomplete. See Kawchuk.
- Boutin RD, Netto AP, Nakamura D, et al. "Knuckle Cracking": Can Blinded Observers Detect Changes with Physical Examination and Sonography? Clin Orthop Relat Res. 2017 Apr;475(4):1265–1271. PubMed #28050816 ❐ PainSci #53241 ❐
This research group used ultrasound to analyze knuckle cracking in real time. “What we saw was a bright flash on ultrasound, like a firework exploding in the joint,” Dr. Boutin said. “It was quite an unexpected finding.” In almost all cases, when a flash was clear in the visualization, there was also a knuckle crack. It’s not clear that the flash and the sound occur at the same time.
There was no pattern of pain, swelling, or disability in knuckles that were cracked.
- Unger DL. Does knuckle cracking lead to arthritis of the fingers? Arthritis Rheum. 1998 May;41(5):949–50. PubMed #9588755 ❐ PainSci #53245 ❐
- Sutker AN, Barber FA, Jackson DW, Pagliano JW. Iliotibial band syndrome in distance runners. Sports Med. 1985;2(6):447–451. “Symptoms often persisted for 2 to 6 months. All runners were treated conservatively with rest, stretching, reduced distance, anti-inflammatory medications, local cortisone injections and/or orthoses.”
Anabolic steroids are derivatives of testosterone and broadly cause growth and facilitate adaptation to biological stresses — muscle growth in response to resistance training, most notably. Because they are derived from testosterone, their side effects infamously caused mood swings, aggression, and impulsiveness.
Fun fact: I actually took anabolic steroids as a kid, medically prescribed to treat “slow growth syndrome.” Interesting experience!
Corticosteroids are quite different, despite sharing the word “steroid” — their effects are also profound and similar in some ways when taken systematically, but they have a much greater anti-inflammatory effect.
- Of course, as everyone now knows, thanks to the Mythbusters, bulls are actually surprisingly nimble and respectful of the merchandise when navigating the aisles of a china shop.
- Noble CA. Iliotibial band friction syndrome in runners. Am J Sports Med. 1980;8(4):232–234.
This study of 73 runners with iliotibial band syndrome showed that most of them experienced relief from one, two, or three steroid injections, most of the remainder recovered with four to six weeks rest, and five cases were finally resolved with surgery.
- Gunter P, Schwellnus MP. Local corticosteroid injection in iliotibial band friction syndrome in runners: a randomised controlled trial. Br J Sports Med. 2004;38(3):269–72; discussion 272. PainSci #56737 ❐
From the abstract: “Local corticosteroid infiltration effectively decreases pain during running in the first two weeks of treatment in patients with recent onset ITBFS.”
- Tonks JH, Pai SK, Murali SR. Steroid injection therapy is the best conservative treatment for lateral epicondylitis: a prospective randomised controlled trial. Int J Clin Pract. 2007 Feb;61(2):240–6. PubMed #17166184 ❐
“On the basis of the results of this study, the authors advocate steroid injection alone as the first line of treatment for patients presenting with tennis elbow demanding a quick return to daily activities.”
- Orchard J, Kountouris A. The management of tennis elbow. BMJ. 2011;342:d2687. PubMed #21558359 ❐ Orchard and Kountouris concluded in a 2011 review of tennis telbow treatments that “Cortisone injections are harmful in the longer term and are no longer recommended in most cases.” Not everyone agrees, but it’s an important opinion to take note of.
- Mohamadi A, Chan JJ, Claessen FM, Ring D, Chen NC. Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clin Orthop Relat Res. 2017 Jan;475(1):232–243. PubMed #27469590 ❐ PainSci #52902 ❐
This review sought the answers in eleven mostly small studies of 700 patients (including three studies that included multiple injections). The answers were disappointing, other than confirmation of minor temporary pain relief. There was no effect for most patients at three months, multiple injections made no difference, and five patients needed to be treated to get good results for one.
Corticosteroid injections provide—at best—minimal transient pain relief in a small number of patients with rotator cuff tendinosis and cannot modify the natural course of the disease. … Their wide use may be attributable to habit, underappreciation of the placebo effect, incentive to satisfy rather than discuss a patient’s drive toward physical intervention, or for remuneration, rather than their utility.
- Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med. 1999 Jun;27(6):393–408. PubMed #10418074 ❐
- I hope that researchers will study the difference between injecting the iliotibial band itself and injecting the lateral recess underneath it, to see if there is any significant difference. This is a great example of how better understanding of iliotibial band syndrome could lead to much more effective treatment in the future: what if a single injection in exactly the right place was much more effective for almost all patients? That would sure be worth knowing!
- Knee performance is critical to some careers, which means unavoidable re-aggravation. If a steroid injection every six months seems to do good, it could be worth doing it for a few years. And obviously you can monitor the knee for signs of trouble. For instance, if steroids always help, but the problem always comes back even worse than before … stop the injections!
- Louw A, Diener I, Fernández-de-Las-Peñas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Med. 2016 Jul. PubMed #27402957 ❐ PainSci #53458 ❐
This review of a half dozen good quality tests of four popular orthopedic (“carpentry”) surgeries found that none of them were more effective than a placebo. It’s an eyebrow-raiser that Louw et al could find only six good (controlled) trials of orthopedic surgeries at all — there should have been more — and all of them were bad news.
The surgeries that failed their tests were:
- vertebroplasty for osteoporotic compression fractures (stabilizing crushed verebtrae)
- intradiscal electrothermal therapy (burninating nerve fibres)
- arthroscopic debridement for osteoarthritis (“polishing” rough arthritic joint surfaces)
- open debridement of common extensor tendons for tennis elbow (scraping the tendon)
Surgeries have always been surprisingly based on tradition, authority, and educated guessing rather than good scientific trials; as they are tested properly, compared to a placebo (a sham surgery), many are failing. This review of the trend does a great job of explaining the problem. This is one of the best academic citations to support the claim that “sham surgery has shown to be just as effective as actual surgery in reducing pain and disability.” The need for placebo-controlled trials of surgeries (and the damning results) is explored in much greater detail — and very readably — in the excellent book, Surgery: The ultimate placebo, by Ian Harris.
- Cohen D. How safe are metal-on-metal hip implants? BMJ. 2012;344:e1410. PubMed #22374741 ❐ PainSci #53447 ❐
- Drogset JO, Rossvoll I, Grontvedt T. Surgical treatment of iliotibial band friction syndrome. A retrospective study of 45 patients. Scand J Med Sci Sports. 1999;9(5):296–298.
From the abstract: “ … surgical treatment of iliotibial band friction syndrome produces good results in patients with insufficient relief of symptoms after conservative treatment.” Almost 50% had excellent results, another 35% had good results, and only one patient had a negative result. However, this should be contrasted with much better results reported by Michels and Hariri, using newer arthroscopic techniques.
- Martens M, Libbrecht P, Burssens A. Surgical treatment of the iliotibial band friction syndrome. Am J Sports Med. 1989;17(5):651–654.
From the abstract: “ … good results, low morbidity, and quick return to sports demonstrate that this type of surgery offers a solution for selected cases of failed prolonged conservative treatment.”
- Michels: “The synovial recess is debrided with thermocoagulation or a synovial shaver. The resection is completed when the bone of the lateral femoral condyle is visible.”
- 81% excellent, 16% good!
- Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002 Jul 11;347(2):81–8. PubMed #12110735 ❐ PainSci #56845 ❐
This is landmark and fascinating study showed that people with osteoarthritis improved equally well regardless of whether they received a genuine surgical procedure or a sham.
From the abstract: “In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.”
Two decades later, this isn’t quite so surprising anymore — many similar studies have been done since — but it was a truly amazing result at that time. It is a particularly striking example of the placebo effect and implies that belief can have an effect even on seemingly “mechanical” problems.
In 2008, these specific results were fully supported by a Cochrane Collaboration review (Laupattarakasem) which concluded that “there is ‘gold’ level evidence that arthoscopic debridement has no benefit,” and by New England Journal of Medicine (Kirkley) which reported that “surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy.”
Surgeries have always been surprisingly based on tradition, authority, and educated guessing rather than good scientific trials; as they are tested properly, compared to a placebo (a sham surgery), many are failing. Moseley 2002 was the first of many to compare orthopedic (“carpentry”) surgeries to shams. By 2016, at least four more such procedures had been shown to have no benefit (Louw 2016), and that trend has continued since.
The need for placebo-controlled trials of surgeries (and the damning results) is explored in much greater detail — and very readably — in the excellent 2016 book, Surgery: The ultimate placebo, by Ian Harris.
- Schwellnus MP, Theunissen L, Noakes TD, Reinach SG. Anti-inflammatory and combined anti-inflammatory/analgesic medication in the early management of iliotibial band friction syndrome. A clinical trial. S Afr Med J. 1991 May;79(10):602–6. PubMed #2028354 ❐
This 1991 experiment compared anti-inflammatory and pain-killing meds to a placebo in 43 runners with IT band syndrome. The authors somehow managed to spin the results as positive, but I can’t see it: when I look at their data, I see no advantage over placebo. I believe that there was technically a small benefit to the medications, but so small that you’d miss it if you blinked. Whoop-de-doo.
- Many athletes practically mainline the stuff before competition. I’ve even done that myself, taking far more than I should because I’m highly gut-tolerant of the stuff — it just doesn’t seem to make me grumbly in my tumbly. However, in a rare case of good science about a fairly minor issue, good experiments have shown that this practice is nothing more than superstition. In 2006, Nieman et al tested the effect of ibuprofen on hard-core marathoners. There were 29 ultra-marathoners on high doses of ibuprofen and 25 controls that completed the race without meds. There was no measurable difference in muscle damage or soreness between the two groups. Lead researcher David Niemen: “There is absolutely no reason for runners to be using ibuprofen.” For more detailed reporting on this research see: Convincing the Public to Accept New Medical Guidelines, by Aschwanden.
And there are other, similar studies. For instance, Semark et al tortured sprinters’ muscles with a savage workout, and the painful results were identical with or without an anti-inflammatory medication. “In conclusion,” they wrote, “the aetiology of the DOMS induced in the trained subjects in this study seems to be independent of inflammatory processes … .” Hmm. Minimal inflammation in delayed-onset muscle soreness too? Not really surprising!
- Heinemeier KM, Øhlenschlæger TF, Mikkelsen UR, et al. Effects of anti-inflammatory (NSAID) treatment on human tendinopathic tissue. J Appl Physiol (1985). 2017 Nov;123(5):1397–1405. PubMed #28860166 ❐ This study reported that “tendinopathic cells are not responsive to ibuprofen.”
- Bittermann A, Gao S, Rezvani S, et al. Oral Ibuprofen Interferes with Cellular Healing Responses in a Murine Model of Achilles Tendinopathy. J Musculoskelet Disord Treat. 2018;4(2). PubMed #30687812 ❐ PainSci #52446 ❐ “We conclude that the use of Ibuprofen for pain relief during inflammatory phases of tendinopathy, might interfere with the normal processes of extracellular matrix remodeling and cellular control of expression of inflammatory and wound healing genes.”
- Wheatley BM, Nappo KE, Christensen DL, et al. Effect of NSAIDs on Bone Healing Rates: A Meta-analysis. J Am Acad Orthop Surg. 2019 Apr;27(7):e330–e336. PubMed #30260913 ❐
This is a meta-analysis of 16 trials, showing that common over-the-counter pain-killers interfere with bone healing. Chronic overuse roughly doubles the risk that a fracture will heal slowly or not at all (“non-union,” a very serious complication).
The effect was not evident in children or in lower doses or temporary usage — this bad news applies only to adults taking too much of the stuff for too long. Unfortunately, a lot of people do that! The pain-killers in question are the non-steroidal anti-inflammatory drugs or NSAIDs like aspirin, ibuprofen, and naproxen — already notorious for several other significant side effects, and yet still widely overused.
- Medication-overuse headaches (MOH), formerly known as “rebound” headaches, are probably mostly caused by dependence-and-withdrawal physiology, like getting a headache when you quit drinking coffee, but it might be more complicated. Pain-killers taken for headaches may be a surprisingly common and ironic cause of headaches (though maybe less of a plague than some headlines have led us to fear; see Scher). This topic is obviously of special interest to patients with unexplained headaches, and so I discuss it a lot in my headache guide, but it’s also just a major side effect for anyone treating anything with pain-killers long-term.
- McGettigan P, Henry D. Use of non-steroidal anti-inflammatory drugs that elevate cardiovascular risk: an examination of sales and essential medicines lists in low-, middle-, and high-income countries. PLoS Med. 2013 Feb;10(2):e1001388. PubMed #23424288 ❐ PainSci #54748 ❐
Diclofenac is an extremely popular painkiller associated with serious cardiovascular risks, as with other NSAIDs: “There is increasing regulatory concern about diclofenac. … Diclofenac has no advantage in terms of gastrointestinal safety and it has a clear cardiovascular disadvantage.”
- Science Based Pharmacy [Internet]. Gavura S. How risky are NSAIDS?; 2015 Jul 25 [cited 16 Aug 18].
A good general discussion of painkiller risks and side effects, but the relative safety of topical treatments is of particular interest:
The main advantage of topical NSAIDs is the reduced exposure of the rest of the body to the product, which reduces the side effect profile. Given the toxicity of NSAIDs is related in part to the dose, it follows that topical treatments should have a better toxicity profile. Consequently, the cardiovascular risks of topical diclofenac, even in those with a high baseline risk of disease, should be negligible with the topical forms.
- McGettigan P, Henry D. Use of non-steroidal anti-inflammatory drugs that elevate cardiovascular risk: an examination of sales and essential medicines lists in low-, middle-, and high-income countries. PLoS Med. 2013 Feb;10(2):e1001388. PubMed #23424288 ❐ PainSci #54748 ❐
Diclofenac is an extremely popular painkiller associated with serious cardiovascular risks, as with other NSAIDs: “There is increasing regulatory concern about diclofenac. … Diclofenac has no advantage in terms of gastrointestinal safety and it has a clear cardiovascular disadvantage.”
- Collins NC. Is ice right? Does cryotherapy improve outcome for acute soft tissue injury? Emerg Med J. 2008 Feb;25(2):65–8. PubMed #18212134 ❐
This is a 2008 review of just 6 studies of therapeutic icing, only two of them any good: one with slightly positive results, the other showing no effect. So that’s two studies that showed little or no benefit, which is leaning towards bad news, but it’s just not enough data to clinch it. (Four animal studies showed reduced swelling, but we can’t take animal studies to the bank.) The bottom line is just that “there is insufficient evidence.”
(See more detailed commentary on this paper.)
- The top priority is to stimulate tissue with “good stress.” Any trigger points in the region matter too, but probably a lot less … and they can be dealt with later at your leisure. They are not at great risk, they are more treatable than the ITBS, and in any case you can be effective with icing ITBS if you confine your icing to a small area on the side of the knee. Don’t feel obliged to spread the ice over a wide area. The inflammation is in a very particular spot, so your icing can be a very particular spot — which substantially minimizes the risk of irritating trigger points in nearby musculature.
- Hing WA, White SG, Bouaaphone A, Lee P. Contrast therapy—a systematic review. Phys Ther Sport. 2008 Aug;9(3):148–61. PubMed #19083715 ❐ If contrasting promotes recovery from exercise, it can’t be much. That fits a general pattern: nothing seems to help with recovery from exercise, I’m afraid. For more about that, see my article about delayed-onset muscle soreness.
- Tweet, Sep 24, 2014, Greg Lehman (@GregLehman), physical therapist and chiropractor.
- Many cases will be “silent” while you rest, and it will be hard to tell if you’re improving or not. A very long resting effort should probably include occasional cautious stress tests to check progress. Especially in the later stages of healing, one stress test isn’t going to set you very far back. But if you discovered that you’re really no better off than you were months ago, the jig is up: pain that isn’t really responding to that much rest probably never will.
- For some people, taking six months or a year off from running really is not a big sacrifice: “Sure, I’ll take a year off … especially if it means I’ll probably get rid of this damn knee pain!” For others, obviously it’s a huge deal. Such decisions are very personal.
- I rested inadequately at least three times, a little longer each time, before it finally seemed to “take.” I probably could have saved myself a lot trouble if I’d just done a much bigger, better rest at first.
- Polaski AM, Phelps AL, Kostek MC, Szucs KA, Kolber BJ. Exercise-induced hypoalgesia: A meta-analysis of exercise dosing for the treatment of chronic pain. PLoS One. 2019;14(1):e0210418. PubMed #30625201 ❐ PainSci #52661 ❐
This is a good quality review of studies of exercise for chronic pain that tried to extract some wisdom about exercise dosage for chronic pain patients. Unfortunately, it failed: the review establishes only that we know essentially nothing about exercise dosage for chronic pain patients. Our ignorance is near total. There’s just not enough of the right kind of evidence to conclude anything, and almost countless confounding factors and variables that have never been studied.
“The lack of dosing studies for exercise means that patients may not be receiving the optimal therapy and/or be receiving a therapy that actually increases pain.”
From a detailed analysis of the review:
Appropriate exercise dosage may not be generalizable beyond the individual patient given their goals and prior activity levels. … Perhaps it isn’t necessary (or even realistic) to find an optimal, generalizable dosage of exercise for pain states, but rather to find appropriate exercise dosage for the individual based on their desired goals.
- Soligard T, Schwellnus M, Alonso JM, et al. How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. Br J Sports Med. 2016 Sep;50(17):1030–41. PubMed #27535989 ❐
- Gabbett TJ. Debunking the myths about training load, injury and performance: empirical evidence, hot topics and recommendations for practitioners. Br J Sports Med. 2018 Oct. PubMed #30366966 ❐ “Rapid increases in training and competition workloads and low chronic workloads are associated with greater injury risk. These findings suggest that appropriately staged training programmes may reduce injury risk in athletes. There is an urgent need for randomised controlled trials to test this working hypothesis.”
- How fast load can be increased without causing injury and how much rest is required without causing re-injury during rehab are not exactly the same concepts, but they are certainly very closely related. The main difference is that healthy and injured people probably have different thresholds for risk of injury versus re-injury. In short, when you’re already injured — which is the case for everyone with a stubborn overuse injury — you probably have to be more careful.
- Many, many factors are involved in energy balance — not all of them under our control.
- A pull buoy is a figure-eight shaped piece of closed-cell foam, which you place between thighs or ankles. It provides flotation support to the lower body, without kicking the legs, allowing the swimmer to focus on training only their arms. For the ITBS victim, it means basically zero knee action. Thanks to reader Eric C. for this simple tip.
- Farrell KC, Reisinger KD, Tillman MD. Force and repetition in cycling: possible implications for iliotibial band friction syndrome. Knee. 2003;10(1):103–109.
- Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 2000;10(3):169–175.
- For instance, hip muscles may react to ITBS pain by “going limp,” and then they recover as the condition resolves. Though it seems at first to fly in the face of Fredericson’s results, the idea is defensible, even plausible. For instance, Mense and Simons write, “Physiologic studies show that muscle pain tends to inhibit, not facilitate, reflex contractical activity of the same muscle … ” (Mense synopsizing Johnson).
- Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment. Sports Med. 2005;35(5):451–459. PubMed #15896092 ❐ “ … weakness or inhibition of the lateral gluteal muscles is a causative factor … ”
- Niemuth PE, Johnson RJ, Myers MJ, Thieman TJ. Hip muscle weakness and overuse injuries in recreational runners. Clin J Sport Med. 2005;15:14–21.
OBJECTIVE: To test for differences in strength of 6 muscle groups of the hip on the involved leg in recreational runners with injuries compared with the uninvolved leg and a control group of noninjured runners.
DESIGN: Descriptive analysis.
SETTING: Three outpatient physical therapy clinics in the Minneapolis/St. Paul metropolitan area.
PARTICIPANTS: Thirty recreational runners (17 female, 13 male) experiencing a single leg overuse injury that presented for treatment between June and September 2002. Thirty noninjured runners (16 female, 14 male) randomly selected from a pool of 46 volunteers from a distance running club served as controls.
MAIN OUTCOME MEASURES: Self-report demographic information on running habits, leg dominance demonstrated by preferred kicking leg, and injury information. Muscle strength of the 6 major muscle groups of the hip was recorded using a hand-held dynamometer. The highest value of 2 trials was used, and strength values were normalized to body mass(2/3).
RESULTS: Results comparing the injured and noninjured groups showed that leg dominance did not influence the leg of injury (chi(2)(1) = 0.134; P = 0.71). Correlations for internal reliability of muscle measurements between trials 1 and 2 with the hand-held dynamometer ranged from 0.80 to 0.90 for the 6 muscle groups measured, and all P values were less than 0.0001. No significant side-to-side differences in hip group muscle strength were found in the noninjured runners (P = 0.62-0.93). Among the injured runners, the injured side hip abductor (P = 0.0003) and flexor muscle groups (P = 0.026) were significantly weaker than the noninjured side. In addition, the injured side hip adductor muscle group was significantly stronger (P = 0.010) than the noninjured side. Duration of symptoms was not a contributing factor to the extent of injury as measured by muscle strength imbalance between injured and uninjured sides.
CONCLUSIONS: Although no cause-and-effect relationship has been established, this is the first study to show an association between hip abductor, adductor, and flexor muscle group strength imbalance and lower extremity overuse injuries in runners. Because most running injuries are multifaceted in nature, areas secondary to the site of pain, such as hip muscle groups exhibiting strength imbalances, must also be considered to gain favorable outcomes for injured runners. The addition of strengthening exercises to specifically identified weak hip muscles may offer better treatment results in patients with running injuries.
- Not IT band syndrome, mind. The hip weakness hypothesis has been just as big a deal for patellofemoral pain syndrome as it has for ITBS, maybe bigger. This first study of the link between hip weakness and PFPS really added to the hype. But for the rest of the story I will ignore the PFPS research and just focus on the ITBS studies.
- Bolgla LA, Malone TR, Uhl TL, Umberger BR. Hip and knee strength, EMG activity, and kinematics in subjects with patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2006 Jan;36(1):A67. PubMed #18349475 ❐ PainSci #55989 ❐ A little more detail about their results: this research team studied a group of 20 women with patellofemoral pain syndrome, and 20 healthy people for comparison — but they emphasize that no causal relationship was established. And they found only “a moderate association” between pain and the strength of external rotation only, and a (still “moderate”) association with some increased EMG (electrical activity) in a key hip muscle, the gluteus medius, and the vastus medialis. Note that the researchers reported no difference at all in hip abduction (gluteus medius) strength, which is the exact muscle at the presumed center of the scientific controversy about hip strength and running injuries. The case for causation is virtually non-existent, and if a perfectly good little study can’t even find an association with gluteus medius strength … well, the whole thing is becoming really sketchy.
- Ferber R, Kendall KD. Biomechanical approach to rehabilitation of lower extremity musculoskeletal injuries in runners. Unpublished. 2007 Jun. Ferber and Kendall studied “284 patients who visited his clinic complaining of leg pain” and found that “92 per cent had weak hip muscles.” They then “gave them a program to improve hip strength, along with other recommendations to speed their recovery.” They claim that the results were “astonishing” — a foolishly emotional word to use in science — with an alleged “89 per cent of the patients reported a significant improvement in pain within four to six weeks.” Exciting! And premature!
- A Google search for “Reed Ferber hip strengthening” turns up many media stories about this idea, and in major publications. An excellent example: in the September, 2009, issue of Runner’s World, Ferber’s theory is the basis of a short article, “All in the Hips” (p. 46). This time Ferber comments himself:
Inadequate hip muscle stabilization is a top cause of injury in runners.
That was a wild-eyed overstatement. Ferber did not actually have adequate evidence for that opinion. Yet he was clearly "promoting" it, without a sign of humility or caution, in the world’s most widely read running magazine, and many others.
Another example: In December 2009, Running Times (no longer available online) uncritically reported on Ferber’s opinions, confidently declaring the precise alleged mechanisms by which hip weakness does its alleged dirty work — every bit of which is debatable, especially the part about pronation — saying definitely that “this is when misdiagnosis often occurs” (as if this isn’t an entirely unproven diagnosis itself), and concluding that “Ferber drives the point home.”
The Running Times article is particularly obnoxious because it heavily promotes ankle pronation as an evil consequence of hip weakness — pronation that Ferber himself denounced as poorly correlated with running injuries earlier in 2009. So not only does the article overconfidently promote an unproven explanation for running injuries, it promotes one that has actually been directly contradicted in print by the same scientist they are enthusiastically quoting!
- Ferber R, Hreljac A, Kendall KD. Suspected Mechanisms in the Cause of Overuse Running Injuries: A Clinical Review. Sports Health: A Multidisciplinary Approach. 2009;1(3):242–246. PubMed #23015879 ❐ PainSci #55475 ❐
The paper concludes that there is “a large and growing body of literature” that backs up the idea that weak hips cause running injuries. Really? “Large?” Not even a dozen weak experiments, none of which clearly show cause and effect, is “large”? And the word “growing” is just a careless, informal exposure of bias: the only relevant thing to say is how much evidence actually exists now.
It’s ironic that this paper points out how correlations alone are not compelling with regards to the role of pronation in running injuries, but the same standard is not applied to the weak-hips evidence.
- Ferber R, Noehren B, Hamill J, Davis IS. Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics. J Orthop Sports Phys Ther. 2010 Feb;40(2):52–8. PubMed #20118523 ❐
This study is a fishing expedition to confirm the (pet) theory that hip strength is a significant factor in ITBS. It is not surprising in a general sense that it found some indications of abnormal running mechanics. What is notable is that the abnormalities do not correspond well or cleanly to the notion that “weak hips” are the problem. Also, typical of studies with results that aren’t that interesting, only the statistical significance of the abnormalities is mentioned, and not their actual size — which was probably small.
- Ioannidis J. Why Most Published Research Findings Are False. PLoS Medicine. 2005 08;2(8):e124. PainSci #55463 ❐
This intensely intellectual paper — it’s completely, hopelessly nerdy — became one of the most downloaded articles in the history of the Public Library of Science and was described by the Boston Globe as an instant cult classic. Despite the title, the paper does not, in fact, say that “science is wrong,” but something much less sinister: that it should take rather a lot of good quality and convergent scientific evidence before we can be reasonably sure of something, and he presents good evidence that a lot of so-called conclusions are premature, not as “ready for prime time” as we would hope. This is not the least bit surprising to good scientists, who never claimed in the first place that their results are infallible or that their conclusions are “true.”
I go into much more detail here: Ioannidis: Making Medical Science Look Bad Since 2005.
- Grau S, Krauss I, Maiwald C, Best R, Horstmann T. Hip abductor weakness is not the cause for iliotibial band syndrome. Int J Sports Med. 2008 Jul;29(7):579–83. PubMed #18050060 ❐
- Noehren B, Schmitz A, Hempel R, Westlake C, Black W. Assessment of strength, flexibility, and running mechanics in men with iliotibial band syndrome. J Orthop Sports Phys Ther. 2014 Mar;44(3):217–22. PubMed #24450366 ❐ PainSci #53183 ❐
- No one trains hip internal rotation. There’s no gym machine for it. You could go to a busy gym for an hour a day for a year and never see anyone working on this movement. That doesn’t mean it doesn’t matter, but it is jarringly at odds with what the hype on this topic was leading people to believe. Probably at least 80% of hip strengthening prescriptions inspired by the weak hips hypothesis are directed at abduction (moving the leg away from the midline), not rotation. And then along comes this study and says, “Actually, abduction strength seems to be fine in runners with ITBS … there might be a little difference in rotation strength.” Good grief.
- Foch E, Reinbolt JA, Zhang S, Fitzhugh EC, Milner CE. Associations between iliotibial band injury status and running biomechanics in women. Gait Posture. 2015 Feb;41(2):706–10. PubMed #25701012 ❐
- Louw M, Deary C. The biomechanical variables involved in the aetiology of iliotibial band syndrome in distance runners - A systematic review of the literature. Phys Ther Sport. 2014 Feb;15(1):64–75. PubMed #23954385 ❐
- Brushøj C, Larsen K, Albrecht-Beste E, et al. Prevention of overuse injuries by a concurrent exercise program in subjects exposed to an increase in training load: a randomized controlled trial of 1020 army recruits. Am J Sports Med. 2008 Apr;36(4):663–670. PubMed #18337359 ❐
- Brown AM, Zifchock RA, Lenhoff M, Song J, Hillstrom HJ. Hip muscle response to a fatiguing run in females with iliotibial band syndrome. Hum Mov Sci. 2019 Apr;64:181–190. PubMed #30743163 ❐
- I think the evidence is overwhelming that they need to be eliminated from our repertoire, or reduced to being a minor adjuvant. It’s not inconceivable that these treatments could be slightly helpful, but they should never be the focus of therapy — it isn’t even remotely justified.
- Muscles will tear before tendons tear! Tendons will rip off a chunk of the bone they are attached to long before they tear (called an avulsion fracture) — because bone has a lower tensile strength and is the weak link.
- If these therapists were trying every possible way of loosening the iliotibial band, I could perhaps forgive their attention to the tendon itself, but they are not: they are typically hammering away at the toughest tendon in human anatomy, while mostly or entirely ignoring the muscles that actually pull on it and control its tension. This reveals a simple-minded fixation on treating the part that hurts without thinking even one step further about why that iliotibial band might be too tight.
- Thixotropy is the property of some gels or fluids that are normally thick (viscous), but thin when they are stressed. In the human body, the synovial fluid that lubricates most joints is thixotropic, as is the gelatinous “ground substance,” which is part of all connective tissues such as tendons and ligaments. (Fun fact: semen is also thixotropic.) Thixotropy is one of the reasons that we loosen up a little as we move around, just like engine oil warming up. However, thixotropic effect is not a therapeutic effect, and does not explain “releases” in massage or fascial therapy: it is too minor, slow, and temporary, and connective tissue is too tough. See Thixotropy is Nifty, but It’s Not Therapy: A curious property of connective tissue is often claimed as a therapy.
- Tendon is proteinaceous and solid (non-layered). Adhesions, by nature, affect layers that slide against each other. With lack of movement, those layers begin to stick, as hydrogen bonds form between the adjacent connective tissues. But there are no layers in a tendon that can get stuck to each other. The extensibility and elasticity of tendon owes itself entirely to the structure of its proteins. They are strung together in long chains with a slight wave or zig-zag, like pleated hair. When the tendon is pulled, the zig-zags flatten. This gives tendon a small amount of extensibility. The zig-zags want to spring back into shape, so the tendon is also an energy storage device — that is, it’s elastic.
- Macdonald G, Penney M, Mullaley M, et al. An Acute Bout of Self Myofascial Release Increases Range of Motion Without a Subsequent Decrease in Muscle Activation or Force. J Strength Cond Res. 2012 May. PubMed #22580977 ❐ The researchers concluded that “an acute bout of SMR of the quadriceps was an effective treatment to acutely enhance knee joint range of motion” — but an 8% short term increase seems unexciting. Greg Lehman points out several key flaws in the study, especially that the control group was not a true therapeutic control group. Jason Silvernail, PT: “My prediction is that those who love foam rolling will talk about this like this is a big deal. It’s not.” Read the full analysis.
- ScienceBasedMedicine.org [Internet]. Hall H. The Graston Technique: Inducing Microtrauma with Instruments; 2009 Dec 29 [cited 12 Oct 11].
- Cheatham SW, Lee M, Cain M, Baker R. The efficacy of instrument assisted soft tissue mobilization: a systematic review. J Can Chiropr Assoc. 2016 Sep;60(3):200–211. PubMed #27713575 ❐ PainSci #53642 ❐
This is the first review of studies of an unusual and controversial massage technique: using tools to “scrape” soft tissue. The authors evaluated seven studies, five of which were controlled, and “the results of the studies were insignificant with both groups displaying equal outcomes.” Although there’s not much good evidence to review, the research so far “challenges the efficacy of IASTM as a treatment for common musculoskeletal pathology.”
One slightly positive note was that there is “some evidence supporting its ability to increase short term joint ROM,” for whatever it’s worth (not much — short term increases in ROM have no clear clinical value in and of themselves). As always, more study is needed, and some benefits might be discovered by studying the right people in the right way, but the first several tests have failed to show any obvious benefit.
- Forman J, Geertsen L, Rogers ME. Effect of deep stripping massage alone or with eccentric resistance on hamstring length and strength. J Bodyw Mov Ther. 2014 Jan;18(1):139–44. PubMed #24411162 ❐
An admirably straightforward test of massage on a few dozen people with tight hamstrings. It showed that a brief application of strong massage strokes parallel to muscle fibres will increase the extensibility of the muscle — not much, and probably not for long, but it’s a measurable effect.
- Low back and hip stiffness and pain is epidemic. Even if trigger point therapy for this region never had the slightest therapeutic effect on ITBS itself, it would probably be worthwhile simply by giving you more comfortable core musculature.
- Wilke J, Engeroff T, Nürnberger F, Vogt L, Banzer W. Anatomical study of the morphological continuity between iliotibial tract and the fibularis longus fascia. Surg Radiol Anat. 2016 Apr;38(3):349–52. PubMed #26522465 ❐
This anatomical study showed that it’s possible that the fibularis (peroneus) longus muscle of the calf is “hardly seperable” from the crural (deep) fascia of the calf, which in turn is connected to the iliotibial tract of the thigh. This suggests that the muscle is probably responsible for some tensioning of the IT band. The clinical significance of this is likely overwhelmed by other factors. For instance, many other calf muscles may also to some degree apply tension to the crural fascia and thus, indirectly, to the IT band.
However, it does illustrate enough of an “everything’s connected” principle that it probably makes some calf massage a worthwhile part of therapy for IT band syndrome.
- Joseph MF, Taft K, Moskwa M, Denegar CR. Deep friction massage to treat tendinopathy: a systematic review of a classic treatment in the face of a new paradigm of understanding. J Sport Rehabil. 2012 Nov;21(4):343–53. PubMed #23118075 ❐
This review of the “efficacy of deep friction massage (DFM) in the treatment of tendinopathy” concludes that there’s basically still no hard data, and “its isolated efficacy has not been established.” However, they offer a firm opinion that technique still makes some good sense despite the important “paradigm shift away from an active inflammatory model since the popularization of the DFM technique by Cyriax.”
- Loew LM, Brosseau L, Tugwell P, et al. Deep transverse friction massage for treating lateral elbow or lateral knee tendinitis. Cochrane Database Syst Rev. 2014;11:CD003528. PubMed #25380079 ❐
- Ingraham. Quite a Stretch: Stretching science has shown that this extremely popular form of exercise has almost no measurable benefits. ❐ PainScience.com. 32838 words. Stretching is not a pillar of fitness: it doesn’t warm you up, prevent or treat soreness or injury, or enhance peformance, but it can cause injuries and (slightly) impair performance. It’s possible to increase flexibility, but the value of flexibility is surprisingy low, even for most athletes. Many key muscles are mechanically impossible to stretch in the first place. Stretch might help some kinds of pain, like muscle pain, but that’s quite speculative. There is no “advanced” stretching method that overcomes any of these limitations.
- Experts have certainly expressed their opinion that it doesn’t work. For instance, Geraci wrote in 2005 that “the typical treatment of iliotibial band syndrome is a stretching protocol that frequently is unsuccessful in the long-term improvement of symptoms.”
- Khaund R, Flynn S. Iliotibial Band Syndrome: A Common Source of Knee Pain. Am Fam Physician. 2005 Apr 15;71(8). PainSci #56763 ❐ From the article: “[Although Fredericson] demonstrates the effectiveness of stretching the iliotibial band, participants in the study did not have iliotibial band syndrome and studies have not demonstrated that stretching hastens recovery from the syndrome.”
- For three good research examples, see Pereles, Brushøj, and Hart.
- Brushøj C, Larsen K, Albrecht-Beste E, et al. Prevention of overuse injuries by a concurrent exercise program in subjects exposed to an increase in training load: a randomized controlled trial of 1020 army recruits. Am J Sports Med. 2008 Apr;36(4):663–670. PubMed #18337359 ❐
- Ingraham. The Unstretchables: Eleven muscles you can’t actually stretch hard (but wish you could). ❐ PainScience.com. 5105 words.
- Willett 2016, op. cit.
- Fairclough 2006, op. cit.
- Eng 2015, op. cit. Briefly recapping: this study shows that the IT band “may contribute to energy savings during locomotion,” an elastic energy storage structure like the Achilles tendon. Although all tendons are extensible to a point, not all of them are equally elastic, and most don’t use their elasticity to actively put energy back into the system (it might only be these two that have that trick).
- Not universally, of course. Some therapists will know this stuff. But let me put it this way: I worked with ITBS patients routinely for a decade, and in that time the number of patients I saw who’d been taught to stretch properly by another therapist … I can count them on one hand. The huge majority were given the standard, inadequate stretch.
- As early as 1979, Noble wrote that, “Tenderness over the lateral epicondyle associated with pain at 30 degrees of flexion on compressing the iliotibial band against the lateral epicondyle is diagnostic.” In 1996 Orchard shows the practical, painful reality of this in the biomechanics of running. In 2006, Fairclough confirmed that tension on the iliotibial band is greatest at 30˚ of flexion.
- Fredericson M, White JJ, Macmahon JM, Andriacchi TP. Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches. Arch Phys Med Rehabil. 2002;83(5):589–592. “Adding an overhead arm extension to the most common standing ITB stretch may increase average ITB length change … in elite-level distance runners.” Not that we can actually change the length of the IT band …
- Falvey EC, Clark RA, Franklyn-Miller A, et al. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scand J Med Sci Sports. 2010 Aug;20(4):580–7. PubMed #19706004 ❐
Researchers studied the anatomy of the IT band on 20 cadavers and tested different IT band stretching methods. They confirmed that the IT band really is “uniformly” and “firmly” attached to the thigh bone, “from greater trochanter up to and including the lateral femoral condyle” — in other words, the full length of the femur. (They also didn’t find a bursa under the IT band in a single cadaver.)
They also carefully measured the mechanical effect of a basic IT band stretch, plus a fancier stretch, and found that even ideal IT band stretching resulted in almost no elongation of the IT band: only about 2 millimeters — an overall change in length of less than half a percent. The IT band is definitely one of the unstretchables.
They concluded with this understatement: “Our results challenge the reasoning behind a number of accepted means of treating ITBS.” One of the authors described their findings thoroughly in a (recent, 2016) blog post.
- Many people will reasonably question the value of a dissection study — so different than the living body! However, the clinical relevance of studies on corpses varies with context. Certainly many things can and have been learned from dissection. In this case, we’re looking exclusively at whether or not an anatomical structure can be elongated when pulled on. It’s not a test of stretching effectiveness in the real world, but of the mechanics and anatomy of the stretch. If a well-executed passive stretch does not elongate the IT band in a corpse, is it likely that a living person could do any better? Do live IT bands respond very differently to being pulled on? I doubt that.
The result is also consistent with a lot of other evidence and with other aspects of the anatomy of the structure, established in this and other studies, particularly that it is anchored to the femur along most or all of its length. It is not an “elongatable” structure. This can be established as well on a corpse as in the living — probably better.
We then can decide what to make of that — that is, what clinical implications arise — but the biomechanical facts are difficult to dispute here. The response that “it’s just a dissection study” is a convenient way to dispose of inconvenient, myth-busting evidence. But dissection studies have their place and are very good at determining things just like this, and that’s why we do them.
- Wilhelm M, Matthijs O, Browne K, et al. Deformation Response of the Iliotibial Band-Tensor Fascia Lata Complex to Clinical-Grade Longitudinal Tension Loading in-Vitro. Int J Sports Phys Ther. 2017 Feb;12(1):16–24. PubMed #28217413 ❐ PainSci #53506 ❐
- This is characteristic of an IT band stretch. Although we know from Falvey et al that the IT band does not elongate, we can still apply tension to it, and it does pull on the joint capsule surrounding the whole knee. The stronger the stretch, the more the knee feels like its being squeezed.
- However, if we want to get into advanced speculation, there is this thing called “specificity of training,” a principle of therapeutic exercise that shows that the body responds and adapts only to the stresses you subject it to. So, if you only do an exercise slowly, you’ll only get good at doing it slowly. So if we suppose that the ITB mobilization works the way that I hope it does — not only stretching the ITB, but also neurologically training the musculature to allow appropriate lengthening of the ITB through complex hip and knee action — then you wouldn’t really want to limit that effect to slow-motion activity only! So I would certainly recommend starting slow and then, as you continue to improve, working up into faster and faster mobilizations, until you reach a practical limit.
- Below-the-knee straps have less obvious relevance to iliotibial band syndrome: they are much more common, and are usually recommended for different conditions, mainly patellofemoral syndrome and jumper’s knee.
- Callaghan MJ, Selfe J, Bagley PJ, Oldham JA. The effects of patellar taping on knee joint proprioception. J Athl Train. 2002 Mar;37(1):19–24. PubMed #12937439 ❐ PainSci #57070 ❐
This article provides an important clue that may help to rationalize the use of a “Patt Strap,” “Cho Strap” or “iliotibial band syndrome strap,” and also suggests a possible mechanism for therapeutic effect on patellofemoral syndrome in particular, as well as other problems. This evidence suggests that proprioception is enhanced by patellar taping. From the abstract: “Subjects with good proprioception did not benefit from patellar taping. However, in those healthy subjects with poor proprioceptive ability ... patellar taping provided proprioceptive enhancement.” Ten years later, the same researchers demonstrated that brain activity is modulated by taping (see Callaghan 2012).
- Callaghan MJ, McKie S, Richardson P, Oldham JA. Effects of Patellar Taping on Brain Activity During Knee Joint Proprioception Tests Using Functional Magnetic Resonance Imaging. Phys Ther. 2012 Jun;9(6):821–30. PubMed #22282771 ❐
After showing that patellar taping improved proprioception (see Callaghan 2002), this straightforward study of brain activity is small and un-powerful, but it also isn’t trying to prove much: just that “patellar taping modulates brain activity in several areas of the brain during a proprioception knee movement task.” This tends to support the notion that taping changes how the knee feels, at least temporarily, which may in turn have an effect on pain.
- Hinman RS, Crossley KM, McConnell J, Bennell KL. Efficacy of knee tape in the management of osteoarthritis of the knee: blinded randomised controlled trial. BMJ. 2003;327(7407):135. PainSci #56583 ❐
The authors conclude that “therapeutic knee taping is an efficacious treatment for the management of pain and disability in patients with knee osteoarthritis.”
- Balachandar V, Barton C, Morrissey D. The efficacy of patellar taping in individuals with patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2011 Dec;45(15):A18. PubMed #22077022 ❐
Does taping help patellar pain syndrome? This review looked at the results of quite a few studies (like Hinman 2003) and concluded that “patellar taping provides an effective means of pain relief in PFPS in the immediate term.” But how does it work? Unfortunately “there is a paucity of research evaluating the effects of patellar taping on PFJ kinematics.”
- Kamper SJ, Henschke N. Kinesio taping for sports injuries. Br J Sports Med. 2013 Nov;47(17):1128–9. PubMed #24159095 ❐ From the conclusion:
Kinesio taping does not appear to have a beneficial effect on pain when compared with sham treatment. Based mostly on studies of healthy populations, there are inconsistent results for other outcome measures such as ROM, strength, muscle activity and proprioception. … At present there appears to be little high quality evidence on which to assess the effectiveness of kinesio taping, it is hoped that future research will clarify the situation.
- It’s a bit unclear how it’s supposed to work, and that puzzle impresses people, makes them assume there must be something clever and “advanced” going on — funny how that works. The idea of something so slight and minimalistic have a significant therapeutic effect also seems impressive. Again, the consumer tends to assume there must be a good explanation for that, or the product would seem ridiculous. Basically “too good to be true” can easily turn into “there must be something to it (because it would be awfully stupid if there weren’t).” Marketing 101!
- Richter RR, Austin TM, Reinking MF. Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis--critical appraisal and commentary. J Athl Train. 2011;46(1):103–6. PubMed #21214358 ❐ PainSci #53613 ❐
A review of studies of foot orthoses to treat overuse injuries of the lower limb with a mostly negative conclusion: “no difference between custom and prefabricated foot orthoses” and “the evidence was insufficient to recommend foot orthoses (custom or prefabricated).” (One thin ray of light was that the evidence supposedly supports the use of foot orthoses to prevent a first injury … but, even if true, hardly anyone seeks out orthoses before they develop an overuse injury. And why would they be good only for a first injury? Makes no sense, therefore likely not true.)
- Chuter V, Spink M, Searle A, Ho A. The effectiveness of shoe insoles for the prevention and treatment of low back pain: a systematic review and meta-analysis of randomised controlled trials. BMC Musculoskelet Disord. 2014 Apr;15:140. PubMed #24775807 ❐ PainSci #53612 ❐
The evidence available on this topic — so far, such as it is, just a few small trials — suggests that insoles or foot orthoses do not prevent or treat back pain, which is hardly a surprise. Technically the evidence is just inadequate and inconclusive, but the absence of any benefit in the small trials done so far is damning.
- McKenzie DC, Clement DB, Taunton JE. Running shoes, orthotics, and injuries. Sports Med. 1985;2(5):334–347. “The runner with cavus feet often has a rigid foot and concomitant problems of decreased ability to absorb the force of ground contact. These athletes have unique injuries found most commonly on the lateral aspect of the lower extremity: iliotibial band friction syndrome; peroneus tendinitis; stress fractures; trochanteric bursitis; and plantar fasciitis. Appropriate footwear advice and the use of energy-absorbing materials to help dissipate shock will benefit these individuals.”
- It’s a “forefoot varus,” meaning that the front of the foot is twisted away from the midline. It’s minor and subtle, but unambiguous. As soon as I could walk, I did so with my right foot turned out. The first time my parents took me cross-country skiing, when I was just a tiny lad about three years old, I had trouble keeping my right ski in the track! It just kept popping out. I tell the story of my funky foot in more detail in my plantar fasciitis tutorial.
- Messier SP, Pittala KA. Etiologic factors associated with selected running injuries. Med Sci Sports Exerc. 1988;20(5):501–505. A tiny study of just a few dozen injured runners found that ITBS was about 20% more common in runners regularly running on crowned roads.
- Here’s a little more detail. The muscles on the side of the hip are mainly postural muscles, designed to keep us standing up straight. We rarely need to lift our legs out to the side — hip abduction is not a particularly useful movement outside of dancing and karate kicking. Instead, those muscles are more for preventing or limiting unwanted hip adduction, the opposite movement. If you step down onto a lower surface with your left leg, your momentum would cause the hip to keep going to the left, while the foot remained fixed on the ground — hip adduction. But the hip abductor muscles arrest this motion, keeping you straight. To do this, they need to contract eccentrically — that is, contracting to slow or stop lengthening. This kind of contraction is well understood to be more tiring than “normal” contraction, which may help to explain why running on a slant may exhaust the hip muscles. See Eccentric Contraction for more.
There’s a lot of research about impact, some of it concerning different surfaces, just a few of those specifically about the relationship between impact and injury. As of the end of 2016, there were only about 18 decent experiments, with too many differences between them to clearly interpret. A review of these by van der Worp et al concluded just a single specific link (stress fractures); otherwise they reported only a broad association between higher loading rates and runners with all kinds of injuries (but none in particular). Davis et al found that “all impact-related variables were higher” in 250 women runners who got injured in a year after extensive gait analysis. And the best evidence so far on barefoot running, from Altman et al, clearly shows that running without padding (barefoot) is problematic.
So while it’s not as obvious or simple as you’d think, the science does suggest some risk. I’ve shared just the tip of the science iceberg here, and there’s a whole article dedicated to the rest: Is Running on Pavement Risky?
- A much clearer example is found in the shoulder (glenohumeral) joint. This joint can be fixed firmly in place by the tendons of the rotator cuff muscle group, or loosened to allow astounding range of motion. And the changes can be fast, the tendons “solidifying” around the joint in a split second or releasing just as quickly. The same thing occurs in several other places in the body where the stability provided by ligaments alone is too limiting.
- Boyer KA, Nigg BM. Muscle activity in the leg is tuned in response to impact force characteristics. J Biomech. 2004 Oct;37(10):1583–8. PubMed #15336933 ❐
Numerous measures of impact and muscle activity were taken in five different types of shoes, with one notable finding: “muscle activity is tuned to impact force characteristics to control the soft-tissue vibrations.” In other words, we minimize the tissue vibrations caused by impact with a subtle but precise muscular bracing, analogous to the way sound-cancelling headphones work — which is pretty cool. The idea of “muscle tuning” has been explored by Dr. Benno Nigg in a series of several papers with various co-authors over many years (see also Friesenbichler 2011).
- Ferris DP, Farley CT. Interaction of leg stiffness and surfaces stiffness during human hopping. J Appl Physiol (1985). 1997 Jan;82(1):15–22; discussion 13–4. PubMed #9029193 ❐ PainSci #53533 ❐
For this classic leg springiness experiment, subjects hopped in place at different frequencies on different surfaces. The purpose of this exercise was “to determine whether leg stiffness is adjusted to accommodate surfaces with different properties,” because “we know very little about the biomechanics of locomotion on substrates other than hard and smooth laboratory floors.”
The effect of different surfaces was dramatic: “The stiffness of the leg spring is increased by as much as 3.6-fold to accommodate decreases in surface stiffness.” In other words, when we’re hopping on harder surfaces, we bend our legs a lot more, like a softer spring. We’re so good at it that “many aspects of the hopping mechanics remained remarkably similar despite a > 1,000-fold change in [surface hardness].”
- Ferris DP, Liang K, Farley CT. Runners adjust leg stiffness for their first step on a new running surface. J Biomech. 1999 Aug;32(8):787–94. PubMed #10433420 ❐
This simple experiment showed that runners adapt to changes in the hardness of the surface they are running on with amazing speed — just a single step — as measured in terms of maintaining the height of their centre of mass. Importantly, this nearly instantaneous adaptation only occurs with an expected change on familiar surfaces, but we are probably pretty quick with unexpected and unfamiliar surface changes as well.
- Typical “prescriptions” of running shoes — the kind you can get from an “expert” shoe seller — are definitely not evidence-based (Richards et al), which is hardly surprising because there is no clear link in the first place between running injuries and the kinds of anatomical quirks (pronation) that these shoes supposedly control (Junior et al). The position of biomechanics expert Dr. Benno Nigg (source):
Nigg has noted that running injuries have not changed over the years despite the massive development of the running-shoe industry. Unlike others, he hasn’t jumped to the conclusion that shoes are bad, or that barefoot or minimalist-running or forefoot-striking is the answer. Instead, looking at the same data, Nigg concludes: Okay, apparently shoes aren’t a big part of the equation.
- Kerrigan DC, Franz JR, Keenan GS, et al. The effect of running shoes on lower extremity joint torques. PM R. 2009 Dec;1(12):1058–63. PubMed #20006314 ❐
As measured in this study, wearing modern-day running shoes designed for stability caused “relatively greater pressures at anatomical sites that are typically more prone to knee osteoarthritis.” The authors acknowledge that it’s hard to know what to make of this, and there are many other potentially relevant variables.
- Keenan GS, Franz JR, Dicharry J, Della Croce U, Kerrigan DC. Lower limb joint kinetics in walking: the role of industry recommended footwear. Gait & Posture. 2011 Mar;33(3):350–5. PubMed #21251835 ❐
Do running shoes have positive or negative impacts on joints? Researchers analyzed peak joint forces in barefoot walking versus three different types of shoes: stability, motion control, and cushion. Results showed an increase in knee and hip flexion forces in all shod conditions during the early stance phase (the part of our gait when we are “standing” for a split second), mostly due to increased step length. This is not clear evidence that “shoes are bad” — more forces are not necessarily bad — but it is an interesting addition to the debate about the biomechanics of shoes versus going barefoot.
- Wunsch T, Alexander N, Kröll J, Stöggl T, Schwameder H. Effects of a leaf spring structured midsole on joint mechanics and lower limb muscle forces in running. PLoS One. 2017;12(2):e0172287. PubMed #28234946 ❐ PainSci #53523 ❐ Although small and based on modelling rather than actual runners, this study is still quite helpful here: a test of the effects of spring-loaded shoes, which concluded that they do indeed “lower limb muscle forces.” This falls short of proving that they actually prevent injury, but it’s more directly relevant than any other evidence available.
- Verdejo R, Mills NJ. Heel-shoe interactions and the durability of EVA foam running-shoe midsoles. J Biomech. 2004 Sep;37(9):1379–86. PubMed #15275845 ❐
Science news flash! Shoes wear out: “Scanning electron microscopy shows that structural damage (wrinkling of faces and some holes) occurred in the foam after 750 km run. Fatigue of the foam reduces heelstrike cushioning, and is a possible cause of running injuries.”
- Kong PW, Candelaria NG, Smith DR. Running in new and worn shoes: a comparison of three types of cushioning footwear. Br J Sports Med. 2009 Oct;43(10):745–9. PubMed #18801775 ❐
When shoes wear out, the biomechanics of running do change. Kong et al tested 24 runners before and after 200 miles of road-running in the same pair of shoes. There were a few minor changes: longer stance phase, less forward leaning, and less ankle flexion. Hip and knee angles were unchanged. (Also, 200 miles is not much — a strangely low number for this study, actually — and the impact on biomechances may only just be getting started by then.)
I do recommend replacing your shoes when they begin to show obvious signs of wear. The risk of running in decrepit shoes may be small, but there’s not much reason to take that risk — just the modest cost of buying shoes somewhat more often. It’s not like you weren’t going to buy new shoes eventually! On the other hand, this data makes it pretty clear that replacing shoes while they still look fine isn’t really going to make much of a difference.
(See more detailed commentary on this paper.)
- Baggaley M, Willy RW, Meardon SA. Primary and secondary effects of real-time feedback to reduce vertical loading rate during running. Scand J Med Sci Sports. 2017 May;27(5):501–507. PubMed #26992659 ❐ “However, forefoot strike and cues to reduce average loading rate also increased eccentric ankle joint work per km. Potentially injurious secondary effects associated with forefoot strike and cues to reduce average loading rate may undermine their clinical utility.”
- Gurney B. Leg length discrepancy. Gait Posture. 2002 Apr;15(2):195–206. PubMed #11869914 ❐
“The role of leg length discrepancy (LLD) both as a biomechanical impediment and a predisposing factor for associated musculoskeletal disorders has been a source of controversy for some time. LLD has been implicated in affecting gait and running mechanics and economy, standing posture, postural sway, as well as increased incidence of scoliosis, low back pain, osteoarthritis of the hip and spine, aseptic loosening of hip prosthesis, and lower extremity stress fractures. Authors disagree on the extent (if any) to which LLD causes these problems, and what magnitude of LLD is necessary to generate these problems.”
- Cooperstein R, Lucente M. Comparison of supine and prone methods of leg length inequality assessment. J Chiropr Med. 2017 Jun;16(2):103–110. PubMed #28559750 ❐ PainSci #52779 ❐
Assessments of leg length are common, both with the patient lying down or standing. Either could be reliable, but in this test they did not agree with each other. Two chiropractors with more than 30 years experience each assessed the same few dozen patients, and agreement between their results when they felt confident in them was “perfectly nil.“ Despite the widespread and confident use of each method, this test clearly suggests that at least one of them is unreliable, but it’s also entirely possible that both of them are.
Way back in 1988, Messier et al found “a greater percentage of injured runners had a leg length difference (greater than 0.64 cm).” But that’s not that subtle a difference. In 1997, Wen et al concluded that “lower-extremity alignment [including LLD] is not a major risk factor for running injuries in our relatively low mileage cohort.” In 2002, Burke Gurney defined the controversy and problems very capably; he certainly didn’t identify a clear relationship between leg length and injury. In 2007, van Gent looked for but couldn’t identify LLD as a risk factor.
And there have just been no significant developments since then.
- ScienceBasedMedicine.org [Internet]. Bellamy J. FTC settles deceptive advertising claims against amniotic stem cell clinics – Science-Based Medicine; 2018 Oct 25 [cited 19 Jan 5]. And here are a couple other older (2015, 2016) critiques of stem cell therapy from my friends at ScienceBasedMedicine.org: FDA Looks At Dubious Stem Cell Clinics (more readable), and Stem cell clinics and unapproved, for-profit human experimentation (more detail).
- CDC.gov [Internet]. Perkins KM, Spoto S, Rankin DA, et al. Notes from the Field: Infections After Receipt of Bacterially Contaminated Umbilical Cord Blood–Derived Stem Cell Products for Other Than Hematopoietic or Immunologic Reconstitution — United States, 2018; 2018 Dec 21 [cited 20 Nov 12].
A dozen patient became seriously ill after receiving injections that supposedly contained stem cells. See also the New York Times coverage.
- Pas HI, Winters M, Haisma HJ, et al. Stem cell injections in knee osteoarthritis: a systematic review of the literature. Br J Sports Med. 2017 Aug;51(15):1125–1133. PubMed #28258177 ❐
- Bohne M, Abendroth-Smith J. Effects of hiking downhill using trekking poles while carrying external loads. Med Sci Sports Exerc. 2007 Jan;39(1):177–183. PubMed #17218900 ❐ PainSci #56827 ❐
For this study, fifteen experienced male hikers walked down a 36˚ test ramp 30 times with poles and 30 times without, and with three different loads: nothing, a light pack, and a heavy pack (30% of bodyweight). A force plate in the ramp measured the intensity of their foot impact, and they were videotaped to get measurements of their joint movement. Consistent with other cited research, the use of poles resulted in significantly reduced forces, movement, and power around the knees and ankles. Interestingly, it didn’t matter how heavy the pack was: “packs only resulted in a larger power generation at the hip.”
- Dagenais S, Yelland MJ, Del Mar C, Schoene ML. Prolotherapy injections for chronic low-back pain. Cochrane Database Syst Rev. 2007;(2):CD004059. PubMed #17443537 ❐ This evidence is discussed in considerably more detail in the prolotherapy section of the low back pain tutorial. In a nutshell, The Cochrane Collaboration concluded that “prolotherapy is not an effective treatment for chronic low-back pain” — and that’s reviewing fifty years of scientific testing of the idea.
- It’s interesting how easy it is to determine this, using modern computer technology. I can easily search through years of my email archives for the term “prolotherapy.” In moments I can display every message anyone has ever sent me that mentions prolotherapy! And, indeed, hardly anyone has ever asked about it, and no one has ever given me a positive case report.
- Sawitzke AD, Shi H, Finco MF, et al. Clinical efficacy and safety of glucosamine, chondroitin sulphate, their combination, celecoxib or placebo taken to treat osteoarthritis of the knee: 2-year results from GAIT. Ann Rheum Dis. 2010 Aug;69(8):1459–64. PubMed #20525840 ❐ PainSci #54963 ❐
Even though knee osteoarthritis makes many lives miserable, long-term studies of treatment options are surprisingly few. This badly needed and good quality experiment compared the efficacy and safety of the two most popular supplements for pain — glucosamine, chrondroitin sulphate — as well as the painkiller celecoxib. They were pitted against each other, a supplement combination, and a placebo, in several hundred patients for two years (valuable long-term data that didn’t really exist before).
Alas, none of the treatments worked — less than 2% of patients enjoyed even a 20% improvement. The study authors conclude: “no treatment achieved a clinically important difference in … pain or function as compared with placebo.” As well, adverse reactions were similar in all groups; serious adverse reactions were rare for all treatments. This adds considerable weight to the already substantial evidence that most popular supplements are totally bogus.
But safe! “All of the tested therapies appeared to be generally safe and well tolerated over a two-year period.”
- It might lift some skin! The mechanics of it would work something like this experiment: (1) put a cookie sheet on the floor, (2) cover it with Saran Wrap, and then (3) try to pick up the cookie sheet with a toilet plunger, through the plastic. Good luck with that. (And you know what? It probably doesn’t even matter if you move that cookie sheet.)
- News.BBC.co.uk [Internet]. Jones M. Malaria advice ‘risks lives’: Some high street homeopaths claim they can prevent malaria, a Newsnight investigation has found; 2006 [cited 12 Feb 19].
Secret filming revealed homeopaths were claiming their preparations could be used instead of anti-malarial drugs to protect travellers in high risk areas such as sub-saharan Africa.
- Ingraham. Homeopathy Schmomeopathy: Homeopathy is not a natural or herbal remedy: it’s a magical idea with no possible basis in reality. ❐ PainScience.com. 1637 words.