How To Fix IT Band Pain

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.

IT Band.png

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.

IT Band Anatomy.png

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.

All in The Hips.png

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.

IT Band Pain.jpg

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.

2014-07-30 22.31.53

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

Lateral band walks (monster walks) and single leg kick outs to the side (unilateral abduction) are other great exercises you can also include in your strengthening phase of treating IT Band pain.

Final Thoughts

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,

SquatBottom
Dr. Aaron Horschig, PT, DPT, CSCS, USAW

With

Kevin Photo
Dr. Kevin Sonthana, PT, DPT, CSCS

 

References

  1. 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
  2. Fredericson M, Guillet M & DeBenedictis L. Quick solutions for iliotibial band syndrome. The Physician and Sportsmedicine. 2000 Feb; 28(2):52-68
  3. Barber FA, Sutker AN. Iliotibial band syndrome. Sports Med. 1992;14(2):144-148
  4. Clement DB, Taunton JE, Smart GW, et al. A survey of overuse running injuries. Phys Sportsmed. 1981;9(5):47-58.
  5. Linderburg G, Pinshaw R, Noakes TD. Iliotibial band syndrome in runners. Phys Sportsmed. 1984;12(5):118-130
  6. 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
  7. Baker RL & Fredericson M. Iliotibial band syndrome in runners. Biomechanical implications and exercise interventions. Phys Med Rehabil Clin N Am. 2016;27:53-77
  8. 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

 

 

 

Published by

Dr. Aaron Horschig

Doctor of Physical Therapy, CSCS, USAW coach and athlete.

13 thoughts on “How To Fix IT Band Pain

  1. If I have IT Syndrome, will I have pain laterally and some posterior in the knee when I sit into a deep squat. I’ve found that I can hop down into a deep squat but standing up I feel very weak in those areas. I did the glute test and it was super weak on the same side as my knee pain. Thanks again for sharing all this info.

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    1. Great question Michael. So usually IT band issues wont cause pain at the bottom of a deep squat but more near the top of the squat. Because you found the weak link with the glute test I would start working on improving that and you should see some good progress!

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  2. My side of the knee on my left leg hurts in the bottom of the squat at parallel, but never when I’m standing. could it be the same issue? My hips are also weak. Thanks

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  3. I don’t have typical IT band or lateral knee pain. It occurs higher up in the leg closer to my quads. I have worked with a pt but he can’t seem to figure out anything besides strengthening the glute med. I have rolled tfl and glute along with lateral quad without much benefit. It seems to mainly affect my ascent on my squat as I can feel it more then. Do you Glauber any recommendations?

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  4. For weight lifting I use the red Adidas you had there.
    For CrossFit workouts I either use Nike Metcons or Inov8 bare foot (not five fingers).
    For running alone… Inov8 bare foot or neutral running shoes.

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  5. Hi!
    I just watched your video, and I think I’m going to try some simpler versions you showed for IT band pain relief! My situation is unique as I had total hip replacement 3 months ago! It’s a second hip…first was a perfect recovery! This 2nd hip is a different story! I see surgeon tomorrow, but PT has diagnosed recent pain issue as IT band! She’s experienced, but I’m not sure about the recent foam rolling which is extremely painful…doesn’t make sense!!! After reading a lot and watching your videos, your explanation and short anatomy lesson makes total sense!!! I am going to do what you have shown as well as light monster walks which I have done previously in PT!!! I also am a fast walker and am up to previous speed pretty much!! Will that exacerbate the IT pain?? I live in San Diego and would be totally willing to pay you for a conversation on the phone!!! Thank you so much for anything you could do!!! Diane

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  6. Hi this in regards to this latest post. Amazing work. Now this post intrueged me and I believe it will help me with my issue. Potentially.

    Can you or anyone help or post something regarding this…

    Now when I walk long distances or squat frequent ass i grass (which I no longer do) I develop a chronic ache down the side of my calf ( peronials ) and into my foot.

    Now I know my internal rotation of my left hip is awful and it’s a journey I have been in trying to solve it. Would this be the main reason to why?

    My TFL cramps a lot when trying to walk and track my feet straight and as I do FRC, 90/90 for my hips.

    Any help would be great. Been seeking help for years and I can never find a solution. I believe internal rotation needs to be increased. Strength my glutes more so and Pails & Rails them to.

    But regarding the lateral calf pain…. cluesless.

    Thank you.

    Like

    1. David! Thanks for the message – It is hard to say 100% the best course of action without first doing my own hands on evaluation. I would say that there is likely something going on at more than just the site of pain. I would recommend going to see a sports physical therapist for an evaluation to really get to the bottom of the issue.

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  7. Hi. I’m a 58 y/o Caucasian female with some serious issues. I have degenerated disc disease L1-L5, severe from L3-L5. Doctors say there is nothing they can do. I’ve also have had my SI Joints screwed and fused as they would not stay in socket as the socket was more open than normal. I’ve recently had issues with my IT Band. I did 8 weeks of formal PT while seeing my PCP for my issue. I did another 8 weeks of formal PT after seeing a Sports Medicine Doctor who then sent me to an Orthopedic Specialist. He diagnosed me with something similar popping hip syndrome, stating my IT Band was catching on my Trochanter and snapping causing my pain in my hip. He did surgery by (his description) cutting a “V” in my IT Band so it could get over the Trochanter. He also stated that my IT Band was TIGHTER than any IT Band he had seen in 25 years of his practice. I did some home PT after instruction from formal PT visit. My Ortho Surgeon stated I should be pain free in 4 months. The surgery did stop the popping over the Trochanter but the pain and popping went higher into my hip area. At 5 months post-op I returned with my complaint of the pain. He said he thinks I have weak pelvic muscles due to my SI joint issues and prescribe 8 weeks more of formal PT. I’m on week 6 now. I’m not seeing any improvement in my pain except right after therapy. By the time I walk out of the session to my vehicle, I’m in just as much pain. I do my therapy excercises almost everyday at home and see my PT twice a week. As a side note, during my sessions, we have discovered my IT Band popping at the knee area every time I raise and lower my knee from a laying position. I’m lost on what I can do next. Any suggestions?

    Liked by 1 person

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