IT Band issues

[Mole J]

I had very painful ITB issues 5-3 years ago. Apart from stretches, Chiro trigger point massage (and dry needles) in my gluteus medius(?), I also used a strap to suppress symptoms when hiking. It immediately reduced the pain. I used the strap for a 2 week backpack in Scotland, and whenever I removed it the symptoms were far worse. I'm not saying it's a cure, but it's certainly a 'painkiller'/coping aid when suffering. With treatment and strengthening exercises (yoga), I no longer needed the band. I carry it as a first aid item, as on some long hill days I sometimes get a flair up.

[Jennifer Mitol]

OK all.

For the most part, you guys have been doing a very nice job of being correct in your assessment of what is wrong and how to fix it in terms of ITB issues. Then it kind of got a bit snarky…..

So here is my profession take on it and how I treat it:

Generally speaking the ITB is a thick, strong, fibrous band of connective tissue that runs from the teeny (yet powerful and generally overused) tensor fascia lata muscle in the front of your hip all the way down the side of your thigh and attaches just distal to the knee. YES, it flicks across the lateral condyle of your femur. Yes it CAN get very irritated in certain situation. NO, it is likely NOT inflammation, but the jury is still out on this (for example – tendonitis has been found to have NO inflammatory cells involved…it's more of a degeneration. This includes plantar fasciitis, achilles tendonitis, patellar, tennis elbow, shoulder tendonitis; hip bursitis is also not at all inflammatory and basically, probably doesn't exist).

But I digress.

The underlying biomechanical problem here is going to be anything that allows the femur to fall inward (towards the other leg). This can be a weak ligament on the inside of the knee, an underlying cartilage tear in the knee that causes minute changes in your gait, weak hips (yep! the weak hip argument again!) that allow your hips to fall inward when you stand on one leg, a muscle imbalance between your hamstrings/gluteals and your quads (quads too strong vs the hams too weak…). This is the same type of condition that can cause patellofemoral pain syndrome: the femur rotates underneath the patella and rubs the condyle against the ITB.

What the strap does it change the location of force away from the condyle – it does nothing in the long term EXCEPT perhaps allow the irritated portion of the ITB to calm down. This is not insignificant…it's why we sometimes tape knees in patients with patellofemoral pain syndrome. Sometimes the injury is truly acute and short-acting, so simply allowing it to heal (without immobility – which is NOT a good thing) and in these cases the strap probably does a pretty good thing.

In chronic cases, though, I'm not sure how the strap would be of any real biomechanical help (placebo should NOT be discounted though…it is very important and as clinicians we are learning how to use it to our benefit). So that means if it works for you…it won't hut so by all means keep using it!

Bottom line, the evidence is mixed that actually massaging out the ITB does any good (but I do it in my clinic with selected patients – without any good evidence one way or the other I stick with my clinical judgement – and it does seem to work in about 50% of my patients). You cannot actually stretch the ITB – so if you can't seem to do that don't worry, you're not doing it wrong, it just really can't be done effectively. If you think you ARE stretching your ITB and it works – great! Keep doing it. But for the vast majority of people there is no effective stretch for it.

Foam rolling is great. Love it. If you can keep that up, do it.

Make sure the shoes you have are the CORRECT ones for you. If you OVERpronate, then working on your tibialis posterior muscle and foot intrinsics to help with your dynamic arch support…use motion control shoes if you need to. I'm not at all the biggest fan of orthotics (they are WAY overprescribed in my opinion), but if you have them and they work for you…don't change.

As for exercises, work on things that challenge you side to side. Specifically work on the glutes, jumping side to side, as well as your butt and hamstrings. What this will do is help to support your femur during standing, particularly on one leg. When your femur is good and strong it won't rotate when it's not supposed to, it won't fall inward when it's not supposed to…and all of that will help to control the aberrant movement of the femur under the ITB (and under your patella, too)

I have some hip muscle and foot arch muscle exercises on my blog backpackerPT.com

Hope this helps!

[Delmar O’Donnell]

> As for exercises, work on things that challenge you side to side. Specifically work on the glutes, jumping side to side, as well as your butt and hamstrings.

Thanks Jennifer, much appreciated. Assume the article with the recommended exercises is under the "Backpacking with Knee Pain" entry?

I currently do the "Dirty Dog" exercise for ITB pain/rehab–would you consider it helpful? Or not so much?

[Greg Mihalik]

Jennifer –
" You cannot actually stretch the ITB – so if you can't seem to do that don't worry, you're not doing it wrong, it just really can't be done effectively. If you think you ARE stretching your ITB and it works – great! Keep doing it. But for the vast majority of people there is no effective stretch for it."

When I was re-habing a knee I was introduced to the foam roller and the "ITB Stretch", and I probably cried a bit as I worked my way through the first week. But after that, to this day, rolling my ITB is no big deal.

So what changed in that first week of rolling? What excruciating bits when away?

Thanks.

[Michael Gartman]

Thanks to everyone, especially Jennifer.

I have been doing the foam roller every day for a few minutes, but I am not getting the intense pain and simultaneous relief I hear everyone talking about…I must not be doing it right? lol

Anyway, I am going on a tester trip today. I am going to switch to my Columbia Peak Freaks instead of my boots, also going to concentrate on taking smaller steps on the downhill. I have a strap I will put on before I take the first step, and may even resort to pre-loading the advil!

We are going to go to the Hog Gap Camp parking area, overnight in the field next to the parking lot, and then attempt to do the Cold Mountain loop tomorrow, finishing up tomorrow on Mt Pleasant, where we will camp…then Sunday, finish the Mt Pleasant Loop. Hopefully my knee will hold up. These two hikes appear to have much less grueling downhill runs.

[Michael Gillenwater]

What Jennifer said!

Rolling does not stretch the IT band, from my understanding. It loosens the connective tissue around the band.

I had this problem last year and had many visits with PTs to permanently address it. Rolling helps, as does RICE. But the ultimate solution for many (including me) is correcting muscle imbalances, which typically relate to weak relatively weak glutes. So exercises like Jennifer wisely advised, especially including knee clams.

It is now an issue I am completely unconcerned with now that glute strength is addressed, although it has to be maintained with regular exercises.

Watch out because there is a lot of garbage info on the internet about this issue.

[Delmar O’Donnell]

You folks doing Knee Clams without, or with resistance (band)?

[Greg Mihalik]

With resistance.

But, IMHO –
Initially, at least, less is better than more, in order to maintain good form.
Once you can get through 30×3 three times a day, With Good Form, then add more resistance.

not a doc, YMMV, HYOH, etc.

[Delmar O’Donnell]

That sounds reasonable. Thanks, will work up slowly. Haven't done Clams before, did a set of no-resistance last night, and a little sore when I woke up this AM. I take that as good sign.

What an odd syndrome, where the cause (butt) is so far removed from the effect (knee). Not intuitive at all.

[Greg Mihalik]

The glute and stabilizers opposite the affected knee, no less.

[Jennifer Mitol]

As for clams, it's a great exercise. I generally do NOT give people resistance…because a) you absolutely need to do it correctly and with resistance you probably aren't, and b) if you need resistance, move on to a harder exercise.

The big cheat here is that your trunk rolls back instead of externally rotating your hip. You need to stabilize your trunk – sometimes I have people lie on their side against a wall – butt and back against the wall – THEN do the clam.

If you can do 20 in a row without difficulty, then it's time to start doing more things in a closed-chain position – meaning standing on a leg. Open chain stuff (your leg moving around in the air) is only good for so much in this type of condition.

As for why it does hurt to roll out those knots, and then it can sometimes feel much better when they're gone – there is actually quite a bit of controversy in the PT world about this. Muscles (contractile tissue) behaves a certain way, and those muscle knots you get (sometimes erroneously called "trigger points") are microscopically and chemically different from the surrounding muscle. When you apply sustained pressure (what the personal trainer earlier posted as a 30-second pressure hold) actually deprives that portion of muscle of oxygen, which causes a cascade reaction that…blah, blah, blah…causes the knot to let go.

The problem with the ITB is that it is NOT contractile tissue. So holding it for 30 seconds SHOULDN'T have the same effect…yet in some people (again, my own personal experience about 50% of patients) it does. Of course, for many people it doesn't, and you can roll out that ITB all day long, press on all the "knots" you feel in there, and nothing changes.

If I find a good answer about what is actually happening to the ITB during rolling I'll absolutely pass it along.

At first blush it seems like it should simply be a mechanical problem with a mechanical solution: areas of fibrotic tissue (think scar tissue like) mechanically broken up by an external mechanical force. Unfortunately, the physiology doesn't match. So just like with tendinopathies, it's time to change the conversation a bit and look more physiologically and chemically at what is happening. But that's the kind of nerdy stuff I get excited about…..

[Michael Gartman]

Went on the short and easy trip. SSDD :(. The strap helped some once I got it tightened real well, but the pain was there just as much as before.

So, beginning this morning, I began going all out on the exercises, the stretching, and the foam roller. I hate it because I had no problems last summer, and I lost 15 lbs off my body and about 6 off my base weight over the winter, and the reward I got was IT Band Syndrome.

I am looking at zero drop shoes, as well as getting a Cho-Pat strap (I used a borrowed Mueller strap), but not thinking they will do much.

Oh well, just have to do my best to deal with it.

[Greg Mihalik]

"I hate it because I had no problems last summer, and I lost 15 lbs off my body and about 6 off my base weight over the winter, and the reward I got was IT Band Syndrome."

Similar story here, but I dodged the bullet.

Getting stronger, and more enthusiastic, I also (unintentionally) lengthened my stride. My hip dropped with each step, tweaking my opposite ITB. Long strides are ok if all the "minor" support groups are playing along. Apparently mine weren't.

I shortened my stride, and did a bunch of strengthening focusing on "hip stability".

n=1. I got lucky.

[Michael Gartman]

Yeah, maybe I did something different on my stride too on our first trip out this year. I don't believe I take long strides, and in fact, I tried very hard to make sure I took very short steps this trip, to no avail. But it may have only taken a misstep or two to tweak something.

It's so strange to me that the pain is upon lifting my foot. When my foot strikes and I put weight on it, there is no pain at all. Another frustrating thing is describing it to others. They ask "how is your knee?" I think they believe I am bs'ing when I say it doesn't hurt at all within 10 minutes of when I stop hiking. I find it odd that I have no pain or soreness now, when a day ago at this time, it was killing me! lol

[jscott]

Jennifer: so at my gym there are two 'sit down' machines with weights which exercise hip adductors/abductors. (I can never remember which is which). Essentially you're doing clams with weights. In one you start with legs apart and close; the opposite for the other. Good exercise?

[Michael Gillenwater]

I am no PT, but I think the pain coming from lifting your foot is normal. The mechanism is irritation of the bone/tissue on the outside of the knee as the IT band (or tendon it is connected too or whatever… I am no anatomist) rubs back and forth over a bony protrusion. As you lift your leg, and especially when walking downhill, is when this rubbing occurs the most.

So it really is not about impact on the knee joint. By correcting the muscle imbalance, primarily in the glutes which is what holds the IT band in place at its top, you can keep it from rubbing in the first place.

Jennifer can correct and/or put this in the proper technical terminology.

Again, my IT issue is totally solved having dedicated to the long term solution of strengthening exercises. Now, though, I'm dealing with some minor shin splits. I repeatedly fail to learn a key lesson, as I keep upping my running mileage too quickly.

[Jennifer Mitol]

They are kind of a good exercise – the pull together ones are for the adductors, the push apart ones are for the abductors.

The reason they aren't better than they are is that you are sitting down, so your pelvis is NOT in the position you want to train at (meaning you need the abductors when you are standing and your hips are pretty much extended, not flexed). But it's not a bad one, I do it…can't hurt of course, but it's not a terribly functional exercise.

[Jennifer Mitol]

Yes, Michael is pretty much correct in that the pain comes from bending your knee, not putting weight on it so much.

Keep it up and don't get discouraged…sometimes these issues can take a while to resolve and the key is not to get too impatient and give up too fast.

I'd stay away from the cho pat strap at this point. Continue to focus on foam rolling, don't worry about the stretches, but DO focus on functional strengthening. That means CLOSED CHAIN exercises. That means exercises for stability with your foot on the ground.

It takes a good 6-8 weeks for strengthening to take place, and in the meantime you need to retrain some of your "motor patterns." That means your body has a certain way it's doing something, the muscles are contracting in a certain order and it's not the correct one. So not only do you have to strengthen, but you have to learn how to fire your muscles in the right way.

[Michael Gartman]

Will commence on the closed chain exercises…and I won't give up, I like backpacking too much!

It is funny how some minute things can be off and cause pain. For example, today I have walked down our office flight of stairs 4 times, with zero pain. I am guessing it is because I am landing with my foot at a 90 degree angle with my leg, so it's not tweaking the IT band at all. Contrast with landing on a downhill trail with your foot forced to start at an obtuse angle, and you get pain.

I did 25 clams on each side this morning, and am feeling it this afternoon, so those are obviously needed! 25 sounds like nothing, but it killed to do that many.

[Michael Gartman]

So I did really well last week in doing my exercises and foam roller at least once a day, and mostly twice. I also bought a strap specifically designed for my IT Band. This past weekend, we went to Catawba and backpacked the Tinker Cliff/McAfee Knob area, which does have some pretty decent downhills.

My knee pain was probably at about 50% of what it was on the previous trip. Not sure whether it was from the exercises, the foam roller, the strap,or the prescription Naproxen my wife had me take at 7 am each morning, but whatever the case, I wasn't in agony! I lean towards the naproxen being the savior, but it all helps.

[Delmar O’Donnell]

> I did 25 clams on each side this morning, and am feeling it this afternoon, so those are obviously needed! 25 sounds like nothing, but it killed to do that many.

I take that as a positive report. It indicates great improvement is possible.

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