Running is a popular sport and while most programs are modified to the beginner runner, more and more people are signing up for races as short as a mile and as long as a marathon. According to Running USA there were nearly 9 million road race finishers in 2007, a 5% increase from 2002. Unfortunately, with an increased numbers of athletes, there are also an increased number of injuries, mainly due to overtraining and lack of strengthening and stretching exercises.

As a massage therapist I often treated clients who complain that their "IT band is tight. They pointed to the outside of their knee and described a dull, sometimes sharp, pain when they walked or ran for long distances. I told them that "IT band is supposed to be tight because it provides stability to the lateral knee. However, it is not supposed to hurt.

What and where is the "IT band"?
IT band or Iliotibial band is a tendinous attachment for gluteus maximus and tensor fascia latae muscles. It runs on the side of the thigh and attaches the aforementioned muscles at the side and just below the knee joint.

How do runners get hurt and what can they do to avoid such injuries?
The pain on the outside of the knee is also known as "iliotibial band friction syndrome and it occurs due to excessive rubbing of the iliotibial band over the lateral bony prominence on the femur (thigh bone)1. The main causes for the excessive rubbing are: downhill running, leg-length discrepancy, increased Q angle (angle between the thigh and the knee), thicker iliotibial band and iliotibial band that are excessively tightened due to shortened gluteus maximus and tensor fascia latae muscles.

Orchard et all1 studied the angles of knee flexion when running or walking at which friction most often occurs and found out that the angle is around or slightly above 30 degrees. They called this zone an "impingement zone. 30 degrees is an angle where braking forces of gluteus maximus and tensor fascia latae are no longer active and as a consequence do not act as deceleration agents to prevent excessive rubbing of the band. In simple words, when the foot lands on the ground the gluteus maximus and tensor fascia latae muscles slow down the speed at which hip and knee flex. However, the slowing down mechanism is no longer in effect at angles during which the most rubbing of iliotibial band happens. Faster running and multidirectional sports are the best alternative after the acute stage of the impingemenet syndrome. The mechanics of the fast running and multidirectional sport such as tennis allow the knee to move quickly through the impingement zone.

Other ways to treat the impingement syndrome are anti-inflammatories, rest and avoidance of slow running. Static stretching also helps:

Some examples of static stretching are:
To stretch gluteus maximus lay on the floor, on your back, both legs straight. Inhale, bend one leg and pull it toward the opposite shoulder while exhaling. Hold for at least 1min while breathing slowly. Switch sides and repeat 2 times at least 2 times a day.

For tensor fascia latae lay on your stomach slightly propped on your elbows. Heels should touch each other; toes should face away from each other. Hold for 1 minute, 2 times with 30 sec rest.

To stretch the IT band itself: lay through the doorframe, left leg touching the frame at knee high. Bring the right leg across the body and place the heel on the doorframe. Knee must be straight and toes pointing toward the ceiling. Hold for 1 min and switch sides. Repeat 2 times.

Answers to commonly asked questions:
Is it all right to downhill running or no?
Downhill running is contraindicated with iliotibial band friction syndrome, especially in the acute stage when the pain is excruciating and only stiff-legged gait is tolerable. Choose multidirectional sports or shorter, faster runs on level ground instead.

Can I participate in running with IS Syndrome?
Yes but only if running is pain free. Treat the problem before it gets worse. However, if you must run, a fast 5K race would be better than a slower ½ marathon.

Does lifting help?
Strengthening exercises will improve overall running mechanics. In addition, stronger muscles will be able to tolerate faster pace running and fatigue later when compared to weaker muscles.

Can I do too much stretching?
My philosophy is moderation. Two sets of a minute of stretching per major muscle group at least two times a day should do the trick. However, make sure that your muscles are warm – stretch after an activity, after you have been in a whirlpool or after a hot shower.

Can a massage therapist help relieve the pain?
Yes. The right type of massage such as deep, slow stroking motions and incorporation of stretching would be recommended. Thai massage would also be an excellent choice.

Conclusion
Iliotibial band friction syndrome is a common injury in runners and can be caused by an array of reasons. Recovery depends on the underlying cause of the injury and whether the athlete is compliant with the treatment. Proper rest when the injury is acute, faster running speeds, stretching and strength training are some examples that would facilitate recovery. Iliotibial band friction syndrome does not mean an end to one’s running career but it is a sign to reconsider the training strategy, for example, running volume, running mechanics, recovery, etc. If you are in doubt about any of the above we always recommend hiring a certified triathlon coach to help you with your training. 

Martina Young, NMT, MA
USAT level 1 coach

Reference:
1.Orchard et all. Biomaechanic of Iliotibial Band Friction Syndrome in Runners.
Am J Sports Med. 1996;24:375-379