Feeling the Burn of ITB

Greg Spindler, LMT, CSET

I often get phone calls from new clients experiencing the very specific, burning pain associated with ITB Syndrome.  As they describe their symptoms, I never fail to travel back in time to a certain high school track practice. It was a cold day, so cold it was even hard to break a sweat. The legs were just not warming up. You know that type of gripping cold. During practice, one of my teammates (one who never complained) kept talking about a pain he was experiencing. At the end of practice, we gathered around him to analyze his concern. Directly on the outside of the knee leading up toward his hip, we could actually see the heating/burning sensation he was complaining about. I was the lucky one who touched it. Well, let me tell you, I placed my fingers on it for about 1/3 of a second before he jumped and screamed to a deafening shrill. ITB syndrome was a-sizzlin'! Ice, rest, and proper treatment were definitely in order.

To understand ITB syndrome, let's begin with what it stands for:

                       I=Illium   T=Tibia   B=Band

The illium is the hip bone and the tibia is one of the bones of the lower leg. The band is the tendon that connects to the tibia and the TFL (Tensor Fascia Latae) muscle before it attaches to the illium. Its function is mostly to stabilize and assist in abduction of the leg.

Following the origin of the short/small muscle of the TFL to the band, and down the outside of the leg, there is the strong and dominant Vastus Lateralis (outside quad).  When running and cycling, these two rub against each other for the same space, causing tremendous friction. Friction causes heat. Excessive heat causes inflammation. Inflammation equals lack of function. This lack of function moves up, down, and around the body in the form of compensations. Who loses? The athlete and his/her gait efficiency. This is ENERGY LEAKAGE! The athlete now has to overexert to perform the simplest movement patterns. It also causes micro trauma in the area (or multiple areas) since the lever systems have been compromised.

At this point, energy is not traveling smoothly in the direction of movement.  Shear forces stress ligaments and tendons, while joints are gliding or twisting. Therefore, the athlete's potential is lost! You might have a great aerobic engine, but if you're leaking energy with your movement or lever systems, you cannot work at your optimum. This is what keeps many from meeting their goals, making the team, getting a scholarship, qualifying for an event, etc. Clean this up, and you'll find you won't have to work so hard to do the same movements.

So, what is the real cause of the pain? Let's examine this by answering some questions:

1. Is the quad overdeveloped, leaving insufficient room for the ITB? This often happens when triathletes and cyclists ramp up their training mileage and strength train together. They do not allow enough time for adaption and recovery so that the soft-tissue can adjust to the new strength/tension relationship of the muscle, connective tissue, and myofascial tissue involved. A rapid increase in training also has a tendency to initiate a trigger point in the Vastus Lateralis. Many times overlooked, this trigger point has a referral zone in the same area of complaint.

2. Is the TFL too tight, creating pressure on the whole length of the quad? A tight TFL can lead to an adhering of the ITB not only close to the knee, but through the track along side the outer thigh. Myofascial tissue gets glue-like when it does not remain supple. Dehydration can be a cause too. Isolated stretching of the TFL might be necessary after proper hydration level is established as long as the hip is showing that it is more neutrally balanced with stabilization.

3. Is the hip rotated forward (anterior), creating a slack and snap pulling on or near the attachment of the tibia on each revolution/gait cycle? A collapsed hip (forward rotation) has many other components including a short quad group, short adhering adductors, and spasmed hamstrings and glutes. These areas must be re-educated to better support the TFL. This is commonly seen when analyzing power of the left vs. right with a spin scan.

4. Is there a lateral rotation of the foot and medial rotation of the knee? A foot that is collapsed and pronated causes instability and weakness (energy leakage). This is commonly associated with lack of range of motion in the ankle, setting up the next injury. It also explains plantar fascitis. With medial rotation of the knee, the connective tissue of the ITB is stressed on the attachment of the tibia. This constant strain can lead to micro tears, and possible pulling away from contact. The pronated foot has to be addressed, otherwise the medial rotation will not let go. This brings on knee issues with its instability. Sadly, knees are the victim of what is going on above and below the knee. It is part of this long chain of events. So make sure that the pain at the insertion site on the tibia is addressed above and below.

5. Is the gluteus medius muscle able to work enough, or is it unable due to trigger points, wherein the TFL has to pick up the extra load? When running, the leg moves from extension to flexion. The gluteus medius assists not only in stabilization, but in propulsion of the hip. If this muscle isn't at 100% efficiency, then the TFL must pick up the load. That isn't its designed job.

6. Is the hip rotated back creating tightness directly on fibrous tissue of the entire length of the lateral quad? This, like the shortened TFL, is the 24/7 spasmed TFL. An obvious example is the cyclist whose one knee swings in and out with every revolution of the pedal stroke. In this state, we can't ignore the multitude of acupressure points, and possible trigger points, that follow this gall bladder meridian line. A treatment plan should include clearing these points as well as returning the hip to closer balance with the other hip. For some, an extension pattern with both hips also needs to be addressed. Both athletes and the general population who get stuck in this extension sub-pattern commonly experience repeated issues with TFL conditions.

As you can see, there are variations of ITB syndrome. It is important to address all of these questions in order to determine proper treatment.

Many athletes feel the pressure of time restraints with their training/racing season, so they opt for quick temporary fixings. Isolated stretching of the proper muscle groups could be helpful.  However, if done in an improper sequence, it could actually make the issue(s) even worse. Ice and rest for several weeks can help if treatments aren't of choice, but this only lessens the symptoms. Some athletes use ant-inflammatory medications for reduction of pain. Again, this is not a solution, rather just temporary relief of the inflammation until the source of pain is determined.

I have always said that nutrition is a big part of healing stressed soft-tissue. Through Dr. Thie's discoveries (Touch of Health), we must remember that lack of Vitamin A can contribute to the TFL's dysfunction. Double check your food intake and make sure it includes foods rich in Vitamin A such as carrots, mangos, spinach, sweet potatoes, cantaloupe, and apricots.  

Just because pain is associated with the ITB and TFL does not mean it is the source of pain.  Look at the body as a whole under weight-bearing stress. Since our movements and activities originate with a weight-bearing load, the assessment must also be weight-bearing. For the best long-term benefits, you must treat the cause. Pelvic balancing is the key. This returns the TFL to a functional state while in flexion and extension of the hip as the athlete runs or cycles. Short term actions leave only short term results. If you have plans for being active for a long time, why not choose the actions that support it?