With better weather comes the desire to exercise outdoors a lot more.  And for many eager runners, cyclists, and hikers, sudden and persisting knee pain can stop your momentum.  Although the standard treatment approach of rest, ice and anti-inflammatory drugs can often help you get back in stride, some people find a harder time overcoming their pain and restricted movements.  This may be because you have one of the most insidious and difficult to treat causes of knee pain – Iliotibial Band Pain Syndrome (ITBS).

Do you have ITBS?

You may have Iliotibial Band Pain Syndrome if you are experiencing the following symptoms:

  • pain along the outside (and sometimes to the front) of the knee that may be felt about half-way up your thigh,
  • Redness and inflammation where it hurts
  • Pain when pressure is applied over the area
  • Sudden pain when putting weight on your leg, such as during running, cycling, climbing stairs, or squatting.

You are also at an increased risk of ITBS if you have previously had a knee injury or low back pain.

Management and Treatment of Iliotibial band syndrome ITBS

There is no single factor that causes ITBS.  It is instead related to a combination of physical characteristics (such as posture & weight), movement coordination (such as running technique), and training variables (such as frequency and intensity of exercise).

The main reasons why ITBS has the reputation of being so difficult to cure is because it causes pain, stiffness and weakness patterns similar to many other lower extremity injuries.  ITBS is often misdiagnosed as patellofemoral pain syndrome (PFPS), meniscus injury, or “runner’s knee.”  It is often looked at as the cause of pain only after other treatment approaches have failed.

ITBS is most often seen in the spring and early summer when many people returning to physical activity increase their frequency and intensity of exercise.  Although there is no single test or measurement to confirm ITBS, the best thing you can do to promote your recovery is to change the frequency, duration, and possibly also the type, of the exercises you are doing.  For example, runners with ITBS may want to switch to using the elliptical trainer or adding deep water running to their program.

Common mistakes in recovery:

It might seem logical to try to relieve tension in the iliotibial band if that is where the pain is coming from.  Dr. Google can provide thousands of sources illustrating how to use a foam roller along the outside of the thigh to try to loosen the area for pain relief.  However, the available evidence points out that this tension is caused by stiffness in the muscle attached at the top of the ITB, called the Tensor Fasciae Latae (TFL).

The TFL has the largest attachment to the ITB and also most often becomes tight or overworked, placing the greatest stresses on the ITB.  In order to be effective, any manual techniques, such as stretching, rolling or massaging, must focus on the TFL specifically.

One of the biggest factors causing a lack of progress and incomplete recovery is when programs leave out exercise as a primary strategy.  Exercise is the most overlooked and poorly understood component of care for ITBS.  Most common approaches inappropriately try to strengthen already overworked muscles, rather than retrain those needed to provide support to the TFL.

Exercises for acute ITBS:

Here are three starter exercises I find helpful for acute ITBS:

  • The Sidelying thigh stretch helps to reduce the tension and stiffness of the TFL. Research has shown that the greatest stretch on the TFL is with the hip in extension while the knee is flexed.  Maximal stretch is achieved past 90 degrees of knee flexion.  Practically, try to reach back with your bent knee without arching your back.  For the best effects, hold the stretch for one minute at the greatest position that is not painful (for details on this, read my article “check your stretch” on how to stretch for different results).
  • The Clamshell exercise helps to specifically retrain the Gluteus Medius muscle to support the TFL during single-legged activities or when pushing with the feet against a resistance. From the same position as the previous exercise, use your glute muscles to lift the top knee while keeping the heels together and hold the top position for a 5 count.  Keep the effort as low as possible to avoid using your TFL in the process.  This helps to reverse the muscle imbalance between your glutes and TFL that contributes to ITB tightness.
  • Bent knee fall-outs are a key tool to help reduce the demand on the TFL by retraining the use of the lower abdominals in controlling pelvic posture during movement. To do this exercise, start on your back with your knees bent, lightly draw your lower abdominal muscles (below the navel) inward away from your waistband.  While holding these lightly, move one knee outward without letting your pelvis follow the knee.  Stop when you either can’t keep the pelvis in a neutral position or can’t control the lower abdominal contraction.  Alternate sides for best results.

How long until I recover from Iliotibial band syndrome ITBS?

Once these become easy, you can slowly progress to light resistance and weight-bearing exercises, and then a gradual return to your prior activity level.  The timeline for complete recovery depends on many factors, such as:

  • the severity of the injury
  • how long you have had it
  • previous knee or hip surgery, including joint replacement
  • hip or knee pain, caused by osteoarthritis, bursitis, or injury
  • previous or current low back pain

Taking these factors into consideration, you should be able to return to your previous activity levels in 6-12 weeks, however, you will also need to use caution in the post-rehab period to avoid re-injury.

Key Points:

Key factors throughout this program include staying pain-free for every exercise, performing the program daily, and only making small increases in duration and intensity.

–  The biggest component of a successful recovery program is early detection and treatment.  If your pain is not improving within one to two weeks, consider seeking the opinion of a musculoskeletal therapist with experience treating ITBS.

– Less is more.  Reduce and/or change your exercises to help take the stresses off the painful tissues and promote recovery.

– Reduce the risks of a recurrence by progressing slowly without any sudden large increases in activity level.  Ensure that you include specialized exercises to support the TFL to relieve ITB tightness.

If you are dealing with persistent knee or leg pain and would like to find out how you can improve your condition to get back to the activities you love, please feel free to contact John Gray, RKin, MSc, CSCS at jgray@orthophysio.com, or call  The Orthopaedic Therapy Clinic at 416-925-4687.

John Gray is a Registered Kinesiologist and Strength and Conditioning Specialist in downtown Toronto.  He helps clients with orthopaedic and chronic medical conditions break through plateaus to return to full activity.