Iliotibial Band Syndrome: ITB cannot be stretched

Iliotibial Band Syndrome (ITBS) is a common overuse injury common with runners and cyclists, especially when their training levels have recently intensified. It was reported as the second most common running injury and most common reason for lateral knee pain in runners. ITBS can also be associated with court sports, strength training (especially from weight-bearing squats), and even pregnancy. Other contributing factors can be leg length differences. ITBS produces burning pain on the lateral aspect of the knee, and exacerbated by running, especially downhill.

It is conventionally believed that the pain is caused by the repetitive movement of the “cabled” iliotibial band (ITB) sliding back and forth across the outer surface of the lateral epicondyle. This mainly occurs in 25° to 30° of knee flexion, irritating the ITB or its associated bursa during repetitive activities such as running. Conventional treatment often locates the sore spots around the condyle and performs cross-fibre friction with the aim to break down the adhesions, which will enhance fibroblast generation and encourage tissue remodelling.

Fairclough et al. questioned this notion that the ITB moves with respect to the lateral epicondyle during knee flexion-extension. In a study published in the Journal of Science and Medicine in Sport in 2007, they stressed that there are several basic anatomy of the ITB that had been overlooked:

(1) The ITB is not a discrete structure but a thickened part of the fascia lata which envelopes the entire thigh;

(2) 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; and a bursa is rarely present but can be mistaken for the lateral recess of the knee.

As ITB is a whole structure, the authors believed that ITB cannot create frictional forces by sliding back and forth over the epicondyle during flexion and extension of the knee. This “illusion of motion” was created by the reciprocal tightening of the anterior and posterior portions of the ITB during knee flexion-extension. They proposed that ITBS is caused by increased compression of the highly vascularized and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle. The pain can be related to a chronic increased tension of the ITB caused by increased tension of the TFL or gluteus maximus muscles.

The authors concluded 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.”

Another study by Falvey et al. (2012) conducted an anatomical examination of the ITB on cadavers. They tested stretching routines for ITB, and measuring the actual lengthening of the ITB by implanting strain gauges in the cadavers’ ITB. They concluded that ITB is very resistant to stretch since it lengthened less than 0.2 percent with a maximum voluntary contraction. Thus, they challenged the idea of stretching the ITB as a treatment for ITBS. They suggested treatment of ITBS should treat the muscular components of ITB and TFL complex.

Many sceptics and internet gurus hailed this study as the definite, claimed that “IT Band Stretching Does Not Work”, “Stop abusing your IT band”, “You can’t stretch the ITB”, “It can not lengthen and it is NOT tight”, “there is no scientific or anatomical reason to believe that any kind of IT band stretch is even possible, let alone an effective treatment”

In the following articles, we asked experienced teachers and manual therapists on the implications of these studies, and treatment strategies for ITBS.

References

Falvey, E. C., R. A. Clark, A. Franklyn‐Miller, A. L. Bryant, C. Briggs, and P. R. McCrory. “Iliotibial band syndrome: an examination of the evidence behind a number of treatment options.” Scandinavian Journal of Medicine & Science in Sports 20, 4 (2010): 580-587.

Fairclough, John, Koji Hayashi, Hechmi Toumi, Kathleen Lyons, Graeme Bydder, Nicola Phillips, Thomas M. Best, and Mike Benjamin. “Is iliotibial band syndrome really a friction syndrome?.” Journal of Science and Medicine in Sport 10, 2 (2007): 74-76.

Read also

• Iliotibial Band Syndrome: ITB cannot be stretched
• ITB: Empirical evidence is the reality—Robert Baker
• ITB: Extrapolating results from research to hands-on manual therapy should be done with caution—Joe Muscolino
• ITB: Our methods still get results; it’s our explanations that need updating —Til Luchau
• Can you stretch the ITB?