Illiotibial Band Syndrome (ITBS) in Soccer Players
Introduction
Iliotibial Band Syndrome is the common term used to describe any one of several conditions that cause pain around the kneecap, also known as the patella.
The two most common conditions include
anterior knee pain syndrome also known as Patellofemoral Pain Syndrome (PFPS), patellofemoral malalignment, chondromalcia Patella ( see our Blog post on this topic )
Iliotibial Band Syndrome ( ITBS)
In this blog we will focus on explaining causes and treatments for ITBS
Incidence
Iliotibial band syndrome (ITBS) is one of the most common causes of lateral knee pain, particularly in individuals involved in sports like soccer. It accounts for up to 5-12% of soccer injuries. ITBS is typically managed conservatively through physical therapy and temporary activity modification.
What is Iliotibial Band Syndrome (ITBS)?
Iliotibial band syndrome (ITBS) occurs when excessive irritation causes pain at the outside (or lateral) part of the knee.
The iliotibial band (ITB), often referred to as the "IT band" is a type of soft tissue that runs along the side of the thigh from the pelvis to the knee.
As it approaches the knee, its shape thickens as it crosses a prominent area of the thigh (femur) bone, called the lateral femoral condyle.
Near the pelvis, it attaches to 2 important hip muscles, the tensor fascia latae (TFL) and the gluteus maximus.
Irritation and inflammation arise from friction between the ITB and underlying structures when an individual moves through repetitive straightening (extension) and bending (flexion) of the knee.
Typically, ITBS pain occurs with overuse during activities such as running, sprinting and change of direction.
ITBS involves many lower extremity structures, including muscles, bones, and other soft tissues. Usually discomfort arises from:
Abnormal contact between the ITB and thigh (femur) bone
Poor alignment and/or muscular control of the lower body
Prolonged pinching (compression) or rubbing (shearing) forces during repetitive activities.
The common structures involved in ITBS are:
Iliotibial band
Bursa (fluid-filled sack that sits between bones and soft tissues to limit friction)
Hip muscles
ITBS can occur in:
Athletes performing repetitive activities, such as squatting, and endurance sports such as running and cycling
Individuals who spend long periods of time in prolonged positions, such as sitting or standing for a long workday, climbing or squatting, or kneeling
Individuals who quickly start a new exercise regimen without proper warm-up or preparation
Signs and Symptoms
With ITBS, you may experience:
Stabbing or stinging pain along the outside of the knee
A feeling of the ITB “snapping” over the knee as it bends and straightens
Swelling near the outside of your knee
Occasionally, tightness and pain at the outside of the hip
Continuous pain following activity, particularly with walking, climbing, or descending stairs, or moving from a sitting to standing position
Pain is usually most intense when the knee is in a slightly bent position, either right before or right after the foot strikes the ground. This is the point where the ITB rubs the most over the femur.
How Is It Diagnosed?
Your physical therapist will ask you questions about your medical history and activity regimen. A physical examination will be performed so that your physical therapist can collect movement (range of motion), strength, and flexibility measurements at the hip, knee, and ankle.
When dealing with ITBS, it is also common for a physical therapist to use special tests and complete a movement analysis, which will provide information on the way that you move and how it might contribute to your injury. This could include assessment of walking/running mechanics, foot structure, and balance. Your therapist may have you repeat the activity that causes your pain to see firsthand how your body moves when you feel pain. If you are an athlete, your therapist might also ask you about your chosen sport, shoes, training routes, and exercise routine.
Typically, medical imaging tests, such as x-ray and MRI, are not needed to diagnosis ITBS.
There are many potential factors. (see picture below)
Dynamic Valgus Alignment and Iliotibial Band Syndrome
Dynamic Valgus happens during normal single leg activities. With poor mechanical control of the Pelvis and Lower Extremity the knee will go into an Excessive Dynamic Valgus . In this case the Patella and the lateral aspect of the Knee Joint (condyle) will come under excessive stress. All these deviations are even more noticeable when striking on the foot during running.
Excessive Dynamic Valgus components:
Pelvis Drop
Femur rotates internally
Tibia also rotates internally
Foot collapses inwards (excessive pronation)
Physical Therapy Treatment
ITB pain rehabilitation is divided into two main phases
Pain Dominant Phase
Load Dominant phase
Overall, these phases aim to maximize loading the ITB while keeping lateral knee irritation capped at a minimum ( in a scale of 1 to 10 lets say below 5 ) either during the session or upon waking the next morning after the exercises.
1 - Pain Dominant Phase
The goal of this phase is to reduce abusive loads and irritation of the ITB while maintaining loading as tolerated. So avoiding the ITB impingement zone (~30 deg knee flexion) .
Exercises for this stage are
ITB mobility drill
Single Leg Bridge
Hip Abduction with Band
Side Plank on Knee
Side Plank on foot
ITB mobility dril
In this exercises the Thomas test position is used as a low-load ITB excursion exercise.
This is a mobility drill with the intention of starting loading the Band and at the same time increasing the extensibility of the quadriceps , hip flexor and IT band .
Recommended doing 2-3 sets of 10 repetitions .
Be sure you keep the other leg against your chest all the time to lock the lumbar spine and be able to create tension without rocking your back or pelvis.
Single Leg Bridge
In this exercise the goal is to target the hip extensor musculature: glutes and hamstrings .
Recommended doing 2-3 sets of 5-8-10 repetitions .
Push on the ground and be sure you reach full hip extension during the bridge for necessary glute activation .
Hip Abduction with Band
The hip abductors play a crucial role in improving ITB pain, the more strength and endurance you develop in this exercise the less you’ll load the band .
I like doing this variation where the top leg is slightly and internally rotated behind the down leg to target the glute mid and decrease the activation of the hip flexors and ITB by avoiding going into hip flexion which is a common compensation during this exercise.
Recommended doing 2-3 sets of 5-8-10 repetitions . Burning at the side is a common feeling and it’s encouraged .
Side Plank on Knee / Side Plank on foot
As a follow up from our previous exercise, The Side Plank is my favorite exercise and one that needs to be mastered if you want to get rid of ITB pain .
Two variations : on knee , simplest one and on foot to increase the lever of the movement and load to the lateral chain .
Recommended doing 2-3 sets of 5-8-10 repetitions . Burning at the side is a common feeling and it’s encouraged .
Phase 2 - Load Dominant phase
Split Squat Progression
The split squat progression is a great exercise to progressively load the ITB at different angles from the easiest one in the lower position to top position and full tension in the ITB.
This exercise loads the relevant musculature and ITB with heavy, slow resistance training.
Be aware that the injured leg is the right one aka as trailing leg . Shift as much body weight as possible through the right foot and leg .
Level 1 - 2 - 3 are identical in how you perform it with the only difference being the Hip Extension and Knee Flexion angle which starts low and progresses to full hip extension and knee flexion combined in level 3 .
Do 6-second repetitions. 3 seconds way down and then 3 seconds up .
Level 1 and 2
Level 3
Overuse: Too much load , too Fast as the cause of ITBS
Overuse, in this case means an overload to the ITB.
Think about building friction or pressure over time: more training ( rapid increase in practices and games), more intensity of the training (hill workouts , repetitive jumps) ...
Returning to playe after a long period of inactivity ...
Too much Load, applied too fast...
In these situations, the Iliotibial band will became irritated first and more painful over time.
Athletes will continue training at the beginning because pain usually goes away with warm up.
As the condition progresses and the root of the problem is not solved , pain will continue increasing in intensity and it will not disappear with warm up, continuing getting worse till one day the athlete can not compete anymore .
So we as therapist will look for recent alterations in sporting activities. Any changes in the frequency, duration and intensity of training should be investigated in detail.
The training program also should be appraised for errors, including increasing exercise intensity too rapidly, inadequate recovery time and extreme hill workouts.
Treatment
Educate the soccer player in the importance of loading the joint progressively. For example, return to play in small amounts and with proper rest time in between practices or games. Increase load very slowly and paying a lot of attention to the Pain during these practices and the pain afterwards to decide when to load the joint again.
Increased tightness and pain in ITB
The ITB is a very thick tissue with almost no ability to stretch so trying to stretch the Iliotbial band is a waste of time.
Treatment
With this in mind, We at White Bay Physical Therapy , use a combination of techniques ( cupping and Instrument Assisted Soft Tissue Mobilization) to modulate and decrease pain in this area, not with the purpose of stretching anything but with the idea of modulating the pain and increasing the tolerance to the activity. By moving the area properly the pain will get better soon.
Foam Rolling: it may help a little bit as well in terms of modulating the pain but be sure your roll it on the side of the thigh from the middle up, Do not foam roll the painful area by the knee, this will only increase the irritation on the band.
Conclusion:
Iliotibial Band syndrome is a complex condition.
Solving this condition requires a comprehensive approach to correct all deficits that can be causing the lateral knee pain .
Research shows that a combination of Hip and Knee Strengthening exercises is the best approach to ITBS
Taping and Orthotics are secondary tools that can be using in the treatment of ITBS
Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages
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Lionel Pannunzio
Physical Therapist
Board-Certified Sports Specialist
Owner of White Bay Physical Therapy
“Keeping Athletes in the game”
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