By Jenna Zajac PT, DPT, PhD. The ITB is essentially a thick band of fascia that extends down the lateral thigh and has distal ITB syndrome rehabilitation can be split into a (1) pain dominant phase and (2) load dominant References:
attachments to the femur, patella, and ultimately Gerdy’s Tubercle on the proximal tibia. ITB
syndrome is one of the most common causes of lateral knee pain in runners. Often an overuse
injury, this can account for up to 14% of running-related injuries. More recent proposed
mechanisms suggest a compression based syndrome in which knee flexion past 30 degrees
compresses the lateral femoral epicondyle with an increase in posterior tension of the ITB. This
compression is proposed to contribute to irritation of the highly innervated fat pad between the
ITB and femur.
What Can Contribute to the Development of ITB Syndrome?
Rapid increases in running volume, downhill running, and a narrow step width—such as running
on a tight trail—combined with excessive hip adduction can elevate the risk of developing ITB
syndrome. While hip weakness is often addressed during rehabilitation for IT band syndrome,
research indicates that it may not be a predictor of the condition but rather a consequence of it.
The biomechanics mentioned, along with a relatively low tissue capacity, are more significant
contributors to the risk of developing ITB syndrome, typically alongside a swift increase in
training loads. Once symptoms emerge, pain may occur even during relatively low-stress
activities.
Runners will often stop or significantly reduce running temporarily to reduce pain, which is
effective in decreasing irritability. However, this approach may give the false impression that the
injury is healing. By avoiding stress on the ITB, the tissue's capacity can actually decrease
further. Consequently, runners may return to running too soon, encouraged by the reduced pain
from rest, only to encounter the same discomfort they initially experienced. This can trap them in
a cycle of repetitive injury, causing them to repeat the same training errors that led to the injury
in the first place.
Treatment of ITB Syndrome
Despite the prevalence of ITB syndrome, there is limited rigorous research on its treatment.
However, progressive overload and graded exposure to challenging activities are consistently
described as integral components of a rehabilitation program. “Stress shielding” or avoiding
loading the ITB is more likely to lead to re-injury due to the runner not addressing the training
errors that contributed to the injury and also not preparing for the biomechanical loads that will
be encountered in the return to run process. When running, structures in the body experience
heavy loads with high energy storage and release in a repetitive and cumulative way. Therefore,
these components should be addressed in rehabilitation through heavy slow resistance training,
plyometrics, and a well-structured return to run program.
phase which aim to maximize loading while maintaining symptoms at a 0-2/10 pain on the
Visual Analog Scale.
The primary goal during the pain-dominant stage is to minimize irritation to the ITB while still
maintaining tolerable loads to enhance tissue quality. Activity levels should remain high,
focusing on exercises that do not aggravate the ITB, which may necessitate a temporary break
from running. Uphill treadmill walking is an excellent alternative, as it increases knee flexion at
heel strike, helping to avoid the ITB impingement zone while reducing the energy storage and
release demands on the ITB. Additionally, using a treadmill limits downhill walking, which can be
irritating. If uphill treadmill walking isn't feasible at first, cycling and swimming are suitable
alternatives. This stage is also a good time to begin progressive hip loading exercises for the
ITB.
A runner can transition to the load-dominant phase of rehabilitation once they can descend
stairs without experiencing pain. One of the essential exercises during this stage is the split
squat progression, which effectively loads the hip muscles and ITB both eccentrically and
concentrically using heavy, slow resistance. At this point, plyometric exercises can be
introduced to enhance the energy storage and release of the ITB, while minimizing the
cumulative fatigue associated with running. Resisted lateral skaters are an excellent example of
a plyometric exercise to include, as they target the posterior hip muscles with significant loading.
After completing the initial stages of rehabilitation, a gradual return to running can be
implemented. To start, runners might find it helpful to run at a moderate incline (about 5%) on a
treadmill for the first couple of weeks. It’s best to avoid downhill and trail running during this
period, as they can place extra strain on the ITB and encourage a narrower step width.
Additionally, incorporating gait training can be highly beneficial, with a simple yet effective cue
being to increase running cadence by 5-10%.
Conclusions
ITB Syndrome can be a difficult injury to manage and frustrating for the runner, especially if
going through a continual reaggravation cycle. It is key to reduce loads during the pain dominant
stage, but also work towards restoring full capacity through a progressive overload approach
and addressing factors that may have contributed to the initial onset of ITB pain.
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