Part 2-The top 5 ITB ‘Friction’ Syndrome myths
A runner’s guide to the rehabilitation of ITB ‘Friction’ Syndrome
Part 2 – The top 5 ITB ‘Friction’ Syndrome myths
Myth 1: The ITB gets ‘tight’
If the ITB itself is not contractile, such as a contractile muscle, than it stands to reason that the ITB itself cannot ‘get tight’. Rather what happens is the underlying muscle tissue beneath the ITB can develop adverse tightness or hypertonicity.
Think of it in these simple terms. If the muscles underneath (vastus lateralis-the outside quadriceps, and biceps femoris-outside hamstring) the ITB get larger than more pressure will be exerted onto the ITB. Because of the orientation of the ITB there will therefore be under more strain as the band courses down the outside of the leg towards its insertion.
Common causes of vastus lateralis hypertrophy and overload can include a runner with poor medial knee muscle strength whereby the knee collapses inwards through the gait cycle resulting in more load literally through the thigh as the hip drops. Cycling can also hypertrophy the vastus lateralis, which may be one reason why ITB friction syndrome clinically seems to have a high incidence amongst triathletes. Furthermore any activity whereby the quadriceps muscles develop hypertrophy may be contributory to a runner’s onset of ITB friction syndrome including heavy leg work in the gym. As for the outside hamstring being hypertrophied/ overactive I tend to see overstriding runners developing tightness/hypertrophy here. I suspect that this may be due to the extra deceleration work that the hamstrings perform as the over-striding runner comes in to foot strike.
So while the ITB itself cannot tighten, the gluteus maximus and TFL can also contribute to band tensioning.
Interestingly in 2007 Hamill et al published findings that actually showed that runners with ITB friction syndrome had a looser ITB band, exhibiting increased strain that elongated more when subjected to load with a concomitant increased strain rate (more rapid elongation) (4).
These findings seemed to contradict the commonly asserted link between a tight ITB band and ITB friction symptoms. They would further imply that stretching the ITB band would further ‘loosen’ the ITB band, potentially worsening symptoms.
Myth 2: you can stretch the ITB.
Stretching is a hugely popularised treatment for ITB syndrome. Given the anatomy of the ITB being dense fascia, interestingly the ITB tissues really do not stretch. The stretching of cadaver ITB was reported to effect a 3-4% increase in length of the ITB, with a significant force being required to do so. In fact it takes about 2000 pounds of force to stretch or deform fascia (hence we can’t break up fascial adhesions-despute popular belief and opinion).
Any stretching of the ITB may in fact just aid to compress the fatty tissue underneath the ITB as you can appreciate in the below image of the classical ITB stretch being performed. Note as the hips are shifted to the left in this picture, the compression at the insertion of the ITB (just below the knee joint) will increase-potentially irritating the symptoms of the runner.
Hence I do not (and have done so for 11years-my entire physiotherapy career to date) prescribe ITB stretches for runner’s suffering from ITB syndrome.
Myth 3: you should foam roller your ITB syndrome
I do not prescribe foam roller work for the rehabilitation of ITB syndrome for injured runners.
Rather I educate the runner that foam roller use:
1. does not actually ‘rehabilitate’ ITB syndrome in and of itself
Rather than using a foam roller with the hope of making the ITB syndrome pain feel better, effective rehabilitation needs to focus on addressing the causative factors that have coalesced together and resulted in ITB syndrome. These factors for ITB syndrome typically include: over striding cadence, deficits in lumbo-pelvic (hip) stability and strength, and sudden spikes in training loads (more on how to address these factors below-read on).
2. has poor evidence to support the purported benefits
While not everything that works in clinic needs to be justified by the literature, findings from the clinic may sometimes yield different outcomes to the scientific literature. If something consistently works in practice, yet there is little supportive findings available from the literature it may simply indicate that there is a paucity of studies being completed, or that the research has merely thus far failed to validate something that truly does work. When this is the case we may term this ‘results based medicine’, and as practitioners we may still prescribe ‘non evidence based’ interventions. While may practitioners treating people for ITB syndrome continue to prescribe ITB foam rollering, I do not as I have not seen positive results from rolling the band over the 11 years I have been in practice.
Research into the effects of foam roller use for ITB syndrome has shown that despite the popularisation of foam rollering, there is in actuality very little clinical evidence supporting this for pain relief or indeed athletic performance.
A 2014 study the authors tested 27 subjects who performed foam rolling or planking exercises before the performed athletic tests such as vertical jump height, isometric force production and agility.There was no significant difference between foam rollering and planking for all four of the athletic tests, hence foam rolling had no effect on performance. A reduced feeling of fatigue post testing was however reported and found to be significant (6).
Myth 4: physios should prescribe foam rolling for ITB syndrome
So with the above in mind what do I recommend if a runner asks (as most do) whether or not they should foam roller their ITB?
My typical response is ‘if you wish’. Meaning that if the runner is focussing on appropriate rehabilitation exercises addressing their strength deficits, addressing their technique etc, and they believe that using the roller will help their ITB symptoms, than I will let them chose if they wish to allocate time to doing it or not. If they elect to foam roll I prescribe 1-3 minutes of rolling.
Permission will also be granted to roll if the injured runner agrees to not not apply pressure directly over the sore region of the thigh at the insertion point of the ITB (so as to avoid further or heightened aggravation). Rather the runner is instructed to focus on the lateral region of the glute maximus, upper ITB region around the TFL, and also the lateral quadricep (vastus lateralis) and hamstring (biceps femoris).
However permission is granted only if the runner will prioritise their corrective hip strength and stability work. I never wish to see a runner prioritise foam rolling in the treatment of ITB syndrome over the true corrective strengthening work (these will follow in this blog series).
Myth 5: foam roller use on the ITB ‘breaks down’ the fascia
Given that fascia cannot itself be deformed and no physical change induced to the fascia by foam rolling, the name ‘releasing’ being a misnomer. So what does rolling actually do to your tissues?
Foam rollering works by altering the input to your nervous system. When you roll over your muscles it sends a signal back to your brain that then sends a signal back to produce temporary relaxation. It also assists in dampening pain signals which is why you may feel better after foam rolling, but this effect has been found to be very short lived.
A 2014 study looked at the impact of 3 minutes of foam rolling on 18 asymptomatic subjects. The pressure pain threshold was tested at three sites along the ITB tract, before, straight after, and then a further 5 minutes after the intervention. The researchers found that 3 minutes of rolling resulted in an immediate increase in pain pressure threshold (ie more pain could be tolerated) at the lower thigh. However 5 minutes after the roller use had ceased the rise in pain threshold had disappeared (7).
Given the short lived positive effect from foam rolling, and the time constrained nature of most recreational runners, I believe the 3-5minutes devoted to foam rolling of the ITB would be better spent working on hip stability and hip strengthening exercises (the best exercises will follow in this blog post series). As outlined above foam rolling should never be prioritised over other corrective exercises for a runner rehabilitating ITB syndrome.
Physio With a Finish Line™,
Brad Beer (APAM)
Author ‘You CAN Run Pain Free!’
Founder POGO Physio
Host The Physical Performance Show
Featured in the Top 50 Physical Therapy Blog
(4) Hamill J, Miller R, Noehren B, Davis I. Clin Biomech (Bristol, Avon). 2008 Oct; 23(8):1018-25.
Lower extremity mechanics of iliotibial band syndrome during an exhaustive run. Miller RH, Lowry JL, Meardon SA, Gillette JC. Gait Posture. 2007 Sep; 26(3):407-13.
(5) Healey, KC, Hatfield, DL, Blanpied, P, Dorfman, LR, and Riebe, D. The effects of myofascial release with foam rolling on performance. J Strength Cond Res 28(1): 61–68, 2014
Vaughan, Brett, and Patrick McLaughlin. “Immediate changes in pressure pain threshold in the iliotibial band using a myofascial (foam) roller.” International Journal of Therapy and Rehabilitation 21.12 (2014): 569-574.
(6) Immediate changes in pressure pain threshold in the iliotibial band after using a myofascial (foam) roller. Brett Vaughana,Patrick McLaughlina,Discipline of Osteopathic Medicine, College of Health & Biomedicine, Victoria University,Melbourne, Australia.Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Australia