If I had a pound for every time I’ve seen someone diagnosed with ITB syndrome whose symptoms in reality had zero to do with the ITB, I’d be pretty well off.
ITB syndrome much like Irritable Bowel Syndrome for the gut, is a term thrown about willy-nilly for lateral knee pain. You may hear phrases like; “your knee tracking is off” or “your Iliotibial band is too tight”. It's important to know that a “syndrome” is just a name for something that covers a set of symptoms.
Firstly lets set the scene and look at the key player; The Iliotibial band (sometimes known as the iliotibial tract) is a thick piece of connective tissue that stems from the outer side of your knee, runs all the way up the outer side of your thigh and joins in with connective tissue of other muscles just above your hip. Its main role is to create stability of the hip and pelvis and to aid with correct posture.
Due to its large area span and the fact that it connects to both the pelvis and the knee, when people experience lateral (outer) knee pain, the ITB is commonly blamed. The knee is a very complex yet sturdy joint that has a huge range of movement but has to deal with massive amounts of pounds of pressure during movement. For this reason, having a strong piece of connective tissue that runs from its outside, all the way up to the hip is very important to prevent a collapse during movement.
Foam rolling of the iliotibial band is form of savage pain that only those that have tried it can attest to. But what if I told you that all those agonising moments rolling it were a total waste of time, would you believe me? Lets get one thing very clear from the outset, the ITB is meant to be really tight. It is made from thick layers of collagen (a type of protein) that serve to hold things together. So using a piece of foam (even if it is a hard foam roller) won’t do much to “soften” or lengthen its connective tissue. The same goes for deep tissue massage of the ITB. It can help alleviate some of the acute sensations of tightness but as soon as you stand and weight bear, the forces running through your limbs will instinctively cause the tissue to tighten up once more, as it is supposed to.
Having a tight ITB is very unlikely to cause your patellar (knee cap) to not track correctly either, or if it is, it is more likely to be a secondary issue to other things.
So what are these things that can cause the knee pain associated with ITB syndrome that are not the ITB?
Look at the following image of the muscles and connective tissue of the lower limbs. You’ll see dozens of muscles. Some, like the rectus femoris are really long and connect from the pelvis all the way down to the lower leg. Others like the popliteus are small and serve a specific role in knee flexion (bending) and supporting of the rear of the knee joint. The point is that each of these muscles serve many different roles at different angles of movement. They work together and against one another to create movement but also to maintain stability and functionality of the joint(s) that they move. Their interactions and the quality/efficiency of those interactions will dictate how well you move and whether you feel any pain or not.
It is far too reductionist to just blame a tight ITB. Maybe it is tighter than it should be? But WHY is it tight or inflamed? This is the single biggest question that requires answering.
Perhaps you have a tight hamstring muscle or lower leg muscle right now. Maybe the major joints of your big toe don’t want to move too well to protect you from a threat that is perceived to be there? Maybe that stiff lower back you’ve had for a few months that prevents you from being able to comfortably tie your shoe laces could be involved? The point is that you are incredibly unique, complex and wonderful. The myriad of factors that all contribute to a healthy, happy knee are as vast and complex as you are an individual.
WHY these muscles or joints became tight painful and inefficient is what matters.
The single largest factor that causes knee pain is movement inefficiency compounded by lots of strenuous activity. Here is an example of a case I worked on a few months back of a gentleman who had classic ITB syndrome symptoms in his right knee that were NOT caused by a tight ITB…
On assessment, it was very noticeable that he had a very stiff, right ankle that didn’t want to move in its full range of motion. if your brain perceives there to be a movement in the ankle that is dangerous (but may or may not actually be so), it will prevent you from doing said movement to protect you. An ankle joint that doesn’t have full range of motion will absolutely affect how efficiently all the muscles further up the chain contract or lengthen. And this is what we found in this individual. The subtle changes to movement ability can, over a period of time result in extra stress running through the knee, hip and lower back. Ultimately, these extra forces can result in inflammation of joints/tendons/ligaments, pain and further inefficiency in movement.
In this case it wasn’t his ITB that was an issue. When we were able to desensitise his nervous system to the perceived threat in his ankle, the joint opened up allowing greater range of motion and the negative affects to the muscles further up the chain were normalised. The end result being pain eradication.
This is but one example of many. The gist to take away from it is that ITB Syndrome is just a name for a set of symptoms and to tackle it requires a personalised approach.
If you have been struggling for a while with these sorts of symptoms, have tried numerous strengthening exercises or spent hours painfully rolling out or massaging your ITB, then perhaps consider taking a different approach.
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