Welcome back to Squat University! For the past 2 weeks we’ve been discussing common causes of knee pain when barbell training. In this article we’re going to dive a little deeper into IT Band Pain (also called Iliotibial Band Syndrome) and show you how to fix this problem.
IT Band Anatomy 101
So what exactly is the IT Band? Well, it’s actually a thick piece of fascia (dense connective tissue) that runs from the top of your hip all the way to the outside (lateral) part of your knee.1 It encloses the tensor fasciae latae (TFL) and also has connections to the gluteus maximus (your largest butt muscle), lateral hamstrings and lateral quads.
What Is IT Band Pain?
Historically, IT Band pain has been thought to be a repetitive overuse injury typically found in runners. Typically with IT Band syndrome, the runner will experience more pain when they run for longer periods. In fact, IT Band Syndrome has been found to encompass upwards of 12% of all running-related injuries. 3-5 However it also appears in the those participating in weight training. The exact reason for why this problem develops however is debatable with some citing the pain as a result of excessive friction while other believe it is a compression issue. Let me explain.
The initial thought process by many was that when the IT Band is excessively tight, it repetitively shifts forward and backward over the prominent part of your femur bone as your knee bends and straightens (called your lateral femoral condyle).2,6 This causes friction underneath the IT Band that eventually results in inflammation and pain.
We’ve found through recent research that the IT Band is firmly attached to the distal femur by strong fibrous strands that prevent it from rolling over the epicondyle as previously thought. In fact, the rolling movement many see when the knee is flexed and straightened is not actually a true movement but instead a shifting in the tension of the IT Band. As the knee is progressively bent, tension is shifted from the anterior to the posterior fibers of the ITB.
For this reason, we believe that the problem is not due to friction underneath the band but instead compression of a layer of highly innervated fat (contains a lot of nerve endings) that leads to pain.1 Thus, it is not the IT Band itself but the tissue underlying its attachment to the lateral knee that is the pain generator in ITB Syndrome (medically this is classified as form of enthesopathy).
What Causes the Pain?
So now that we know what IT Band Syndrome is and how to test for it, let’s now talk about why this issue started in the first place. In the movie Happy Gilmore, Adam Sandler’s character had a golf coach named Chubbs who loved to say, “It’s all in the hips.” And boy was he right.
The muscles on the sides of your hips are responsible for two main actions, moving your leg away from your body and postural stability. When we perform barbell lifts (squat, clean, deadlift, etc.) these muscles turn on and ensure your knees stay in line with your feet (i.e. limit knee collapse).
One of these large muscles responsible for stabilizing the knees is called your glute medius. The posterior aspect of this muscle (the part closer to the back of your hips) has the job of externally rotating your hip and therefore limits internal rotation collapse of your knees. However, if this muscle isn’t firing correctly (coordination problem) or is just plain weak, the body will start to compensate by calling upon some of the smaller muscles to work overtime in order to limit this unwanted knee collapse.
Typically, the muscle that is often over recruited is the TFL. This muscle isn’t necessarily very strong, but it does attach to a very thick and fibrous piece of tissue (the IT Band) that runs down the rest of the leg, connecting directly to the knee. When the TFL contracts excessively it places tremendous tension on the IT Band in an effort to stabilize the knee.
Problem solved, right?
Unfortunately no. While the TFL can help abduct the leg, it is also an internal rotator of the hip. As the body becomes fatigued, this small muscle does not limit internal collapse of the knee.2 Eventually the body starts moving poorly and the excessive tension of the IT Band leads to harmful compression at the insertion point of the lateral knee and pain eventually sets in.
How To Test for Glute Medius Weakness
First, find a partner. Lay on your side with your legs on top of each other in a straight line. Next, have your friend lift your top leg up and backwards (hip abduction). Make sure to keep your leg in a neutral position (don’t turn the foot outwards).
As you hold your leg in this elevated position, have your friend attempt to push your leg down. If you can hold your leg up without your hips rolling backwards or forwards, or your foot turning outwards, you have sufficient strength in your glute medius. For many with IT Band Syndrome, this test is difficult to perform and your leg will be easily pushed back to the start position.
How Do You Fix IT Band Pain?
Early Phase: Soft Tissue Work
The first step in treating this problem is to treat the symptoms of tissue stiffness. This means soft-tissue mobilizations.
“But, I heard you shouldn’t foam roll the IT Band?”
Recently I’ve heard some people demonize foam rolling for treatment of IT Band Syndrome. They’ll often cite the fact that the pain is caused due to compression of the fat pad, so therefore compression treatment of the actual IT Band doesn’t bring out lasting results and can make symptoms worse by creating even more compression.
Let’s break down this assumption.
When I was going through physical therapy school, we had an anatomy lab where we dissected cadavers and physically cut into the IT Band. Let me tell you, it is an extremely thick piece of tissue. For this reason, deep tissue work like foam rolling isn’t likely to make a ton of a change in tension. However, the IT Band also has fascial connections to many other muscles of the lower leg (which are like a spider web of connective tissue that encapsulates and connect all of the muscles of your body).
When foam rolling your lateral leg, you’re not only hitting your IT Band. You’re also rolling over tissues that connect to the IT Band such as the Vastus Lateralis (lateral quad), Biceps Femoris (lateral hamstrings), Glutes and TFL. Restrictions in these muscles can contribute to excessive tension on the IT Band.2 Trigger points in these muscles can even refer pain to the lateral part of the knee, mimicking the exact symptoms of IT Band Syndrome. For this reason, foam rolling the lateral thigh to address restrictions in these connections can be extremely beneficial at decreasing lateral knee pain.
Start by laying on a foam roller and searching out painful trigger points in your lateral leg (holding pressure on these tender areas for 60 seconds at a time).7 I wouldn’t roll over the painful spot on the outside of your knee, as extreme compression on that specific area of inflammation could make symptoms worse.
Step 2: Strengthening Phase
Once some of the pain has subsided with deep tissue work we then need to address why the pain started in the first place. This means addressing glute medius weakness we talked about earlier.
The most efficient way to hit the glute medius is with side-lying leg lifts. Research has shown this exercise is able to isolate and activate this muscle 20% more than any other movement.8
Lay on your side with your bottom leg bent in front of you and top leg straight. Brace your core muscles and lift your upper leg slightly (keeping it completely straight) without letting the toes turn outwards or rotate towards the ground. Hold this position for 3 seconds before slowly lowering back to the start position.
Recommended sets/reps: 2 sets of 20 reps
Another simple exercise to use early on in the treatment process is the clamshell. Lay on your side with your knees bent. Rotate your top leg upwards like a clam opening its shell. Hold this position for 3 seconds while squeezing your glute muscles. Make sure to keep your low back from rotating during this movement. To increase the intensity of this exercise, place a resistance band across your knees or strap a weight across your leg.
In order to have lasting results with our strengthening, we’ll need to eventually perform corrective exercises that mimic real life movements (i.e. functional training). The touch down squat is the first exercise I want to share with you today.
While standing on a small box, perform a single leg squat by engaging your hips (hip hinge) and keeping your knee in line with your feet (no knee collapse!). Gently tap your heel to the ground and return to the start position.
Do this movement in front of a full-length mirror and watch for what happens at your pelvis. Most people who have IT Band pain will be unable to keep their hips level and will allow their free leg hip to drop during the squat as compensation for poor coordination/strength of the glute medius. It’s also common to see the knee rotate inwards towards the big toe. Work to keep your hips level and your knee in line with your 3rd or 4th toe during the execution of this squat.
Recommended sets/reps: 2 sets of 20 reps
Another great strengthening exercise is the single leg Romanian deadlift (RDL). Along with the single leg squat, these exercises are two of the best at activating both the glute medius AND glute maximus.8
Start in a single leg stance with stable tripod foot (doing this exercise with your shoe off at first to focus on your foot stability can be a good idea). Hold a small weight (dumbbell or kettle bell works great) in your hand opposite of your stance leg.
Brace your core and drive your free leg backwards while lowering your chest forward towards the ground (maintain a slight bend in your knee the entire time). I like to use the cue to use your hip as the center of a teeter totter. If you’re doing this correctly you’ll feel the hamstring of your stance leg tighten and NO tightness in your lower back. Ensure your knee stays in correct alignment with your stable foot the entire movement (no internal rotation!).
Recommended sets/reps: 2 sets of 15 reps
Treating IT Band syndrome takes a comprehensive approach of soft tissue and strengthening/coordination work to find lasting results. I hope this article was able to help you understand this injury a little more and why foam rolling can and should be a part of this process. If you are unable to find relief with your lateral knee pain after performing these exercises, I recommend going to a medical professional (doctor or physical therapist) to assist in your recovery.
Until next time,
- Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat. 2006; 208:309-316
- Fredericson M, Guillet M & DeBenedictis L. Quick solutions for iliotibial band syndrome. The Physician and Sportsmedicine. 2000 Feb; 28(2):52-68
- Barber FA, Sutker AN. Iliotibial band syndrome. Sports Med. 1992;14(2):144-148
- Clement DB, Taunton JE, Smart GW, et al. A survey of overuse running injuries. Phys Sportsmed. 1981;9(5):47-58.
- Linderburg G, Pinshaw R, Noakes TD. Iliotibial band syndrome in runners. Phys Sportsmed. 1984;12(5):118-130
- Orchard JW, Fricker PA, Abud AT, et al. Biomechanics of the iliotibial band friction syndrome in runners. Am J Sports Med. 1996;3:375-9
- Baker RL & Fredericson M. Iliotibial band syndrome in runners. Biomechanical implications and exercise interventions. Phys Med Rehabil Clin N Am. 2016;27:53-77
- Presswood L, Cronin J, Keogh J, Whatman C. Gluteus medius: applied anatomy, dysfunction, assessment, and progressive strengthening. Strength and Conditioning Journal, 2008;30(5):41-53