By Dr. Johnathan Edwards
Have you been told that you have iliotibial band syndrome? It’s the most confusing injury for so many cyclists. Usually, the story goes, “Once upon a time your iliotibial (IT) band wasn’t bothering you, but now it is.” What happened to cause such a scenario? After hours of frustrating online searches about IT band syndrome, you arrive at a plethora of confusing facts: foam rolling helps, foam rolling does not help, anti-inflammatory medications help, no studies are showing that anti-inflammatories help, ice the IT band, never ice the IT band, and the list continues. Should you copy what your friend did to rid their IT pain? Should you foam roll? Should you stretch? Drop your saddle? Scrap your bike fit and start all over? Wedges or insoles in the shoes? Not ride and just rest? What exercises can help?
At its core, iliotibial band syndrome (ITBS) is a common overuse injury in cyclists. The exact cause of ITBS is not well understood, and there is no consensus on how to manage it properly. ITBS is one of the many different causes of lateral knee pain. In cyclists, it is associated with prolonged cycling and movement of the knee through flexion and extension.
WHAT IS THE IT BAND?
In geeky medical terms, the iliotibial band is the distal fascial continuation of the tensor fascia latae, gluteus medius and gluteal maximus. It traverses superficial to the vastus lateralis and inserts on the Gerdy tubercle of the lateral tibial plateau and partially to the supracondylar ridge of the lateral femur. There is also an anterior extension called the IT band that connects the lateral patella and prevents medial translation of the patella.
The non-geeky description is a dense, fibrous connective tissue called fascia on the outside of the leg connected to bones, muscles and ligaments. It starts at the top of the pelvis on a prominent bony ridge called the ilium and runs down the outside of the thigh, connecting just below the knee joint (lateral aspect of the tibia). The ITB is a big sheet of connective tissue that’s strong enough to suspend a car from a bridge. Really!
WHAT DOES THE IT BAND DO?
The ITB helps to extend and flex our knee and is affected throughout the pedal stroke. A remarkable aspect of these issues is that they can respond to increased stress—the higher the stress, the denser the tissue becomes. It exerts a compressive force on the joint when the fascia tightens. This can work in our favor, or sometimes it can work against us.
The ITB helps facilitate the function of the true hip stabilizers and prime movers by providing an attachment to two essential muscles of the hip—the gluteus maximus (other attachments as well) and the tensor fascia latae. For simplicity, when you flex your hip, as you bring your pedal to the top of the stroke, the ITB is influenced via the tensor fascia latae. And when you extend your hip, driving force to the pedals through the effective part of the pedal stroke, the IT band is again influenced via the gluteus maximus. When you ride a bike, your ITB is affected throughout the pedal stroke, and it is being pulled a little forward and backward with every pedal stroke.
WHAT CAUSES ITBS?
Currently, the exact etiology of ITBS is not well understood. It is often described as friction occurring between the IT band and the lateral femoral condyle when the knee is flexed to around 30 degrees. The friction is said to lead to inflammation and pain. However, the findings of cadaver studies and biopsies of the area lead researchers to challenge this theoretical model. Surgical examination of the area often reveals a lack of inflammatory response. Anti-inflammatory medications are often prescribed but often have little benefit. There may be an underlying cyst or extension of the joint capsule laterally in a few cases.
Sub-optimal mechanics is the most common culprit, which is nearly always the case with overuse injuries. Friction between the IT Band and the underlying muscle tissue and bony contacts are often the cause. In any case, the cells that make up your ITB are not happy. In the case of the cyclist, this is highly repetitious friction. As you already know, the gluteus maximus and tensor fascia latae interact with the IT band, and therefore can be looked upon as the most likely sources of your troubles.
Ask yourself these questions to help find a starting place:
• Have you recently increased volume or intensity on the bike?
• Have you changed the position of your saddle?
• Have you changed shoes, cleats, pedals or insoles?
• Is your bike in proper working order? Is your seat rail bent or busted? Are your cleats worn out?
• Have you recently started running, hiking, resistance training, etc.?
• Are you going through any treatments that may affect your hip
What can be done about ITBS? It is important to acknowledge several things: ITBS is complex. You have executed millions of pedal strokes to get here, so a quick fix to your pain is unrealistic. You must be committed to solving your case of ITBS to pedal pain-free.
Physical therapy exercises like stretching, strengthening, manual therapy, and neuromuscular re-education are usually prescribed. Deep friction massage is often used, but outcome research does not support it. Too often in the clinical management of ITBS, the focus is ultrasound, static stretching and myofascial techniques directly to the ITB. Physical therapists need to address underlying dysfunctions and compensatory patterns. Here, we will focus on the exercises and stretches of the muscles and joints involved in ITBS.
The synergies between muscles to coordinate complicated movements lose their ability to talk to each other. Simply said, we cyclists often forget how to use our hip muscles except when on a bike. Think of it as the lack of a quality neurological signal to the gluteal muscles. Many gains on the bike are associated with resistance-training progression and due to neurological adaptation. The muscles and the brain need to communicate to get things rolling in the right direction. The proper exercises, done in the proper order, with the proper load and frequency, and in ideal form can quickly improve muscle function. Various stretches, squats, lunges and any of their variations can lead to significant increases in function.
Perform squats using proper form to increase gluteal muscle strength and activation.
NO FREE LUNCH
As for the foam roller, there are many different schools of thought and where most of the debate exists treating ITBS. The physiological mechanism involved lies within the muscle, not the connective tissue of the ITB itself. Many believe that you can roll out the ITB with a foam roller, which is a myth and technically impossible. Rolling the entire length of the ITB is a painful endeavor. It’s painful because there are many nerve endings in the ITB, and the femur exists in very close proximity and doesn’t like being smashed—that pain is telling you politely to do something different.
If you are using a foam roller, realize it is a way to massage the muscles around the ITB. And which muscles should you target? The gluteus muscles and the tensor fascia latae. Foam rolling should feel good. If it doesn’t, you’re doing something wrong. Try a softer roller or move your body around to reduce the amount of pressure. Another good exercise is to roll a tennis or lacrosse ball on those muscles. This loosens up those muscles in the area. Again, this should not be overly painful.
The complexity of the hip and the IT band is immense. And, as I mentioned early on, if it’s taken you a lot of work to create an injury, there’s going to be a lot of work involved in alleviating your situation. Rider positioning, equipment choices, muscular function (or dysfunction) and continuous self-care are all part of the healing equation. But fear not, I am a former IT band pain sufferer, too, and have used all of the above information myself to find relief. Be patient. There is no “free lunch.”
THE FOUR STRETCHES
1. Forward fold with crossed legs
Start in a standing position with your feet together. Cross your right leg over your left leg, setting your right foot down to the outside of your left foot. Reach down towards your left foot and breathe deeply. Hold for 30 seconds as the muscle releases. Do the same with the opposite foot. Repeat five times.
2. Supine IT band stretch
Lie on your back with your knees bent. Lift your right leg over your left knee, hooking your right ankle around your left knee. Then use your right leg to pull the left leg down to the right. Hold for 30 seconds. Do the same with the opposite leg. Repeat five times.
3. Belt/strap stretch
Lie on your back. Loop a belt or strap around your right foot. Lift your right leg up straight before bringing it across your body (to the left) while keeping your hips flat. You should feel a gentle stretch along your right outer thigh. Hold for 30 seconds. Do the same with the opposite foot. Repeat five times.
4. Side-lying IT band stretch
Lie on your left side with your legs together and your hips and knees bent. Keeping your knee bent, move your right leg behind you and allow it to drop down until you feel a gentle stretch in the side of your right thigh. Hold for 30 seconds. Do the same on the opposite side. Repeat five times.