Not about FRICTION anymore, the myths about iliotibial band syndrome.

Do you still prescribe IT band stretch to athletes with IT band syndrome?

IT band syndrome has long been thought to result from friction between of the tight IT band and lateral epicondyle of femur. It may sound reasonable in the beginning.
In fact, IT band syndrome is an overuse injury related to training load error. Either abrupt increase in running distance or training intensity will increase the injury risk. However, there are some terrible misunderstandings that make athletes spend their time on useless stretches. Let’s take a look at the newly found facts that may oppose to what we used to call “general concepts.”

The IT band is a ligament-like structure well fixed to the lateral thigh. 

• The proximal part of the IT band is a three-layer structure. The superficial and intermediate layers are part of the fascia of Tensor Fascia Lata muscle. The deep layer extended to the hip joint and merged with the joint capsule. 
• The middle part, or the tendon part of the IT band connects to the fascia of vastus lateralis muscle and posterior hamstring muscle. 
• The distal part of the IT band also collects fascia fibers from lateral thigh muscles, attaches to Gerdy’s tubercle at lateral tibia and further continues to form part of the lateral collateral ligament of knee. 

The IT band is so strong and firm that nearly responds to mechanical tension force. 

According to a cadaver research, The total length of the iliotibial band remained almost the same after repetitive stretching.

Instead of friction, soft tissue under the iliotibial band I fact undergoes compression during the movement of the lower extremity. 

The compression is greatest with the eccentric load when the hip is slightly extended and adducted with the knee joint flexed. It happened to be the posture of the trailing leg when we walk downstairs or run downhill. And that is the reason trail runners are more susceptible to IT band syndrome.

Return to Sports from iliotibial band syndrome

Nowadays, we have the athletes to stay active when the acute pain subsided. Rehabilitation programs should be started to prepare for returning to sports.

1. Gait analysis is helpful in detecting risky gait pattern such as cross-over gait, trunk wobble or hip drop. Prolonged ground contact time is another factor to be corrected. Ground contact time in elite athletes may be as short as 170 ms while it can exceed 220 ms in marathon enthusiasts. Velocity-based training may be the key method to shorten the ground contact time. 
2. To achieve maximal exercise load, we make the athletes to run upslope on treadmill. The compression force is less likely to increase during upslope running and thus can keep athletes in better physical activity status. 
3. Core muscle strengthening is important because trunk and pelvis tilting/drop/rotation tend to increase if the core muscles do not play their role as stabilizers effectively and efficiently. Lateral drop of the hip also place the body in the posture more vulnerable to ITBS. 
4. Lateral hip muscles strengthening is another essential program to prevent from recurrence of ITBS. Followings are exercises frequently prescribed to athletes by the author. 

• Clam shell exercise 

• Side raising of leg 

• Monster walk (side walking) 

• Romanian split squat 

• Romanian split deadlift 

• Pistol squat 

Back to our question, will you still prescribe stretching exercise for your athletes suffering from ITBS? If your athletes feel more steady and sure with stretching or massage, the better targets are the muscles contracting the IT band. Therefore, tensor fascia lata, gluteal maximum, vastus lateralis, and lateral hamstring muscles are the muscle to be stretched and massaged.


How do you think about the ideas? Welcome to bring up your opinions.

References：

1. Hyland, Scott, and Matthew Varacallo. "Anatomy, Bony Pelvis and Lower Limb, Iliotibial Band (Tract)." StatPearls [Internet]. StatPearls Publishing, 2019. 
2. Jelsing, Elena J., et al. "Sonographic evaluation of the iliotibial band at the lateral femoral epicondyle: does the iliotibial band move?." Journal of Ultrasound in Medicine 32.7 (2013): 1199-1206. 
3. Devan, Michelle R., et al. "A prospective study of overuse knee injuries among female athletes with muscle imbalances and structural abnormalities." Journal of athletic training 39.3 (2004): 263.
4. Ali, Mohammed, et al. "The use of platelet-rich plasma in the treatment of greater trochanteric pain syndrome: a systematic literature review." Journal of hip preservation surgery 5.3 (2018): 209-219.