IT Band Syndrome: We Have A Weak Link

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“The single most important factor in predicting and possibly treating IT band problems is hip abductor strength.” John Davis, Running Writings

A weak link is found

My last post discussed finding and fixing our weak links. Well, during a trail run I found a weak link and the quest is on to bring it up to a respectable level. At this point I’ve boiled it down to poorly functioning glutes–the glute medius to be specific. Glute dysfunction is fairly common and I’m realizing more and more that I’ve had a good dose of it for quite some time. It’s gotten better but I’ve got to make it better yet. Right now this weak point is causing me some knee pain.

Inside IT band syndrome

Lateral epicondyle; where IT Band pain is typically felt

Lateral epicondyle; where IT Band pain is typically felt

Recently, while finishing a long trail run, I began to feel the dreaded symptoms of IT band syndrome (ITBS). Chances are, if you’re a runner then you either have or you will experience this issue too. If you look at the Wikipedia entry on ITBS you realize this is a mysterious ailment that might be caused by a myriad of issues from the feet to the hips, from the muscles to the bones, from too much running or cycling or rowing or dancing or whatever else you might do on one or two legs. Conventional treatment ranges from ice to ultrasound to stretching to orthotics and various pain drugs like ibuprofen.  (Do we really think that ITBS was caused by a lack of ibuprofen or an absence ice sitting on our knee?) I want to fix this issue and clarify what’s at work here. Let’s see if I can make some sense.

IT Band insertion

IT Band insertion

ITBS symptoms

The most typical symptom of ITBS is lateral knee pain, somewhere in the neighborhood of what you see on these two pictures. That’s where the IT or iliotibial band inserts. As is typical, I felt a sudden onset of pain at this site while running downhill. It’s a fairly sharp pain. Knee flexion while stepping down off a step often brings it on. Apparently, ITBS can be felt elsewhere along the IT band.

  The research: It’s all about the hip abductors.

I found some superb articles with some very valuable information regarding the root cause(s) of ITBS and how to address the issue. Biomechanical solutions for iliotibial band (IT band) syndrome / ITBS comes from RunningWritings.com.  Glutes rehab – recent research and Gluteus medius – evidence based rehab come from Running-physio.com. There is some overlap between these articles and they all refer to quite a bit of important research.  If you’re a trainer who’s working with someone who has ITBS or if you’re suffering from ITBS, I strongly suggest you read these articles. I’ve summarized some things but definitely go to the sources for a thorough rundown.

Both sources cite a study from Stanford, and here’s what you need to know:

“Long-distance runners with ITBS have weaker hip abduction strength in the affected leg compared with their unaffected leg and unaffected long-distance runners. Additionally, symptom improvement with a successful return to the pre-injury training program parallels improvement in hip abductor strength.”

Some sources suggest that foot/ankle dysfunction–specifically over-pronation–is at the cause of ITBS rather than hip dysfunction. Irene Davis and others of the University of Delaware studied both the hips and feet/ankles. They stated:

“However, aside from this variable [an increase in rearfoot inversion moment], these results begin to suggest that lower extremity gait mechanics [i.e. foot and ankle] do not change as a result of ITBS. Moreover, the similar results of the current study […] suggest that the aetiology of ITBS is more related to atypical hip and knee mechanics as compared to foot mechanics. Therefore, the current retrospective study provides further evidence linking atypical lower extremity kinematics and ITBS. (Ferber et al.)”

The Running Writings article discusses several other studies that had similar findings to the Stanford study. The writer reached this conclusion:

“At this point, the evidence overwhelmingly points to a biomechanical fault in the abductor muscles of the hip as the root cause for IT band syndrome.  Weak or misfiring gluteus medius, gluteus minimus, or tensor fasciae latae muscles are unable to control the adduction of the hip and internal rotation of the knee, leading to abnormal stress and compression on the IT band.  This muscular dysfunction manifests as excessive hip adduction and knee internal rotation, both of which increase strain on the iliotibial band and compress it against the fatty tissue between the lateral femoral epicondyle and the IT band proper, causing abnormal stress and damage. But although the pain is coming from the lateral knee, the root of the problem is coming from the hip muscles.”

(By the way, the hip abductors of which I speak consist of the gluteus maximus, gluteus medius, gluteus minimus and the tensor fascia latae or TFL.  See below.

Here’s something important: Very often the glute medius doesn’t do its share of the work and the TFL does too much work. Therefore it becomes important to condition the glute medius while de-emphasizing TFL activity. The side-lying hip abduction exercise (described below) works particularly well for activating the glute med while minimizing TFL activation.)

Hip abductors.  If they're weak, your knees will probably hurt.

Hip abductors. If they’re weak, your knees will probably hurt.

The Running Writings piece also says, “a doctoral thesis by Alison Brown at Temple University also investigated (hip abductor) muscle strength in runners with and without ITBS; interestingly, she found no difference in maximal strength, but a significant difference in endurance.”

On a slightly different note, a recent study in Medicine and Science in Sports and Exercise indicates excessive hip adduction (adduction is the opposite of abduction; If you adduct too much then you’re not abducting enough.) is a precursor to patellofemoral pain or PFP. So again, we see abnormal hip mechanics playing a role in knee pain in runners.

Finally, the Running Writings article does a nice job of dispelling some myths about ITBS, among them the idea of foam rolling and/or stretching the IT Band. I won’t go into all of it but the bottom line is: Don’t bother. The IT band isn’t the problem–it’s the hip abductors! Work on them.

Tredelenburg gait

What happens when those hip abductors fail to do their job? We get what’s called Trendelenburg gait. Here’s a picture of it.  Notice the right

Trendelenburg gait

Trendelenburg gait

hip drops. When that happens the hip muscles on the left are stretched which puts prolonged tension on the IT band. That excess tension may cause pain at the IT band insertion located on the knee. There’s your pain.

Testing the abuductors

Heeding the observation that hip abductor endurance is key to ITBS, I tested that endurance using the old-fashioned, Jane Fonda-style side-lying hip abduction. (I elected to forgo leg warmers.) I got to almost 30 reps on my right leg (the affected side) and the hip was dying. I got to 30 reps on the left leg and with only moderate fatigue. I’ve seen similar performances in several other clients and my wife who also has some ITBS. This all fits in line with what this research found.

The exercises

The two articles from RunningPhysio do a great job of discussing a wide variety of exercises that engage the glutes. In Glutes rehab: recent research we see research on the exercises that elicit the most contraction from both glute medius and glute max. Look at the tables below to see which exercises get the most out of these muscles. (I’m not sure exactly how all of these exercises were performed.)

wpid-Photo-5-Nov-2012-1944 wpid-Photo-5-Nov-2012-2022

Here’s RuningPhysio’s take on how to apply this information:

Practical application

From the research findings a good programme for runners wanting to target GMed would be starting with single leg mini-squat, side-lying abduction and pelvic drops and progressing to single leg dead lift, single leg squat and side-lying bridge to neutral. For advanced work you could add leg weight to side-lying abduction or combine side plank with upper leg abduction. This set of exercises would start with at least moderate GMed activation and progress to in excess of 70% MVIC. It would contain both functional weight-bearing exercises that are a closer fit to the activity of running, and non-weight bearing activities like side-lying abduction which has been shown to activate GMed without increasing unwanted activity in TFL and anterior hip flexors (McBeth et al. 2012) and has been used successfully to rehab runners with ITBS (Fredericson et al. 2000).

Runners wanting to improve GMax could start with single leg bridge, lunge with neutral trunk and single leg mini-squat and progress to single leg squat, single leg dead lift and forward step up. All of these exercises are ‘closed chain’ single leg activities where the GMax provides power to extend the hip but also works to help stabilise the hip and pelvis. As a result they are fairly functional for runners as GMax has a similar role during running.

In Gluteus Medius: Evidence-based rehab, the writer very wisely discusses differences in what we might call “functional” vs “non-functional” exercises. (This article also describes most of the exercises you’ll want to employ.) Generally, we might say a functional exercise would look like something we do in real life. A 1-leg squat or 1-leg deadlift is an example. These exercises have us standing (weight bearing) and using the whole body in concert. We don’t isolate a muscle in a functional exercise but rather we train a movement pattern and integrate lots of muscles together. In contrast, a non-functional exercise tends to isolate a muscle. The side-lying abduction or side plank are examples of non-functional exercises. These exercises don’t much resemble anything we do during most of our daily activities or sports. That doesn’t mean they don’t have value though, and the article does a nice job of discussing this issue.  The article states:

“Closing thought, from the research I’ve read and patients I’ve seen, a combination of both functional weight bearing and less functional (sidelying) exercises is most likely to be effective in glutes rehab.”

My process

Like I said, my right glute med is indeed easier to exhaust than my left. I figure though that I should work both sides with a little extra work on the right. I’ve been doing lots of the side leg raises and side planks.  I can’t yet do a good side plank while abducting the top leg. That’s a tough one. It’s one to shoot for in the future. I’m also doing a lot of band walks.  I don’t loop the band around my ankles though, I loop it around my feet. This study determined that placing the band around the feet recruits more glutes and less TFL. These are sort of the non-functional exercises that I do pre-workout or first thing in the morning.  

Pre-workout or throughout the day:

  • side-lying hip abduction: 2-3 sets x 10-20 reps.  I go to exertion.
  • side planks: 2-3 sets x 10-20 seconds
  • band walks: I side shuffle as well as walk forwards and backwards. I go to exertion.
  • Hip hikes: Easy to do. This movement has you lifting the pelvis away from the Trendelenburg gait pattern.

Functional/main exercises:

  • 1-leg squat: 3 x 8-15 reps. I recently used a kettlebell in the arm opposite my stance leg.  I focus on keeping my pelvis level, knees somewhat apart and I don’t let my non-stance side hip drop which is very important. I also throw several reps in randomly throughout the day.

  • 1-leg deadlift 3 x 8-15 reps: I often hold one or two kettlebells, dumbbells or a barbell.

  • Off-set step up: 3 x 6-12 reps use a knee-high plyo box for this. I hold a dumbbell on the side opposite my stance leg. I drive up powerfully with the stance leg then do my best to control my descent back down. I don’t plummet back down uncontrolled.

  • ice skaters: 3 x 12-20 reps. This is a power exercise in which I drive side to side in an explosive manner. There’s no way to do this without using the glute medius.

  • 1-arm carries/farmer walks: I carry a kettlebell in one hand and walk. Very functional and simple to do.

These exercises do a great job of conditioning our movement sling system. Read here and here to learn more about these systems of muscles that work together as we move.

Awareness

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When it comes to either pain or performance issues, we’re often told that we need to get stronger.  We need to strengthen our core to help back pain.  We need to strengthen our legs to pedal or run faster.  We need stronger arms to swim better.  Strength is important for sure. There’s no substitute for it.  It’s money in the bank.

Awareness and pain

Here’s something slightly different to consider:  Awareness.  A lot of pain and poor performance issues aren’t so much strength-related as they are awareness-related.  By this I mean we need to know how to use our muscles to control our limbs and a lot of us don’t have the awareness we need to accomplish the task.  Here’s a common example:

A client complains of knee pain.  I watch them squat, walk up and down stairs, and maybe do some one-leg mini-squats.

The glutes aren't doing their job and the knees suffer for it.

I observe a valgus collapse–the knee or knees cave in as he or she moves.

What are the consequences?

This type of movement pattern sets us up for knee ligament damage, meniscus damage, IT band pain, patella pain, and possibly back pain.  Even if the person isn’t in pain, this is a very inefficient movement pattern.  Whether running or walking, this valgus pattern makes for poor shock absorption and energy transfer into the ground. We’re slow and weak when our knees collapse like this.

Why is it happening?

Back to the “A” word, awareness.  Very commonly we can’t use our glutes correctly–and we’re not aware that we’re not using them.  We have what Thomas Hanna calls “sensory motor amnesia.” We’ve forgotten how to move.  (Modern living is a killer.  We sit too much!!)

Why do glutes matter to knees?

The glutes (glute maximus, medius and minimus) along with the tensor fasciae latae start up in the pelvis and feed into the IT band.  The IT band then attaches to the top of the tibia right below the knee.  In this arrangement, if we tighten or squeeze the glutes the knee will rotate outwards.  If we release tension from the glutes then the knee will tend to collapse in.  Control of the knee largely resides at the hip with the glutes.  (By the way, we could discuss awareness of the foot as it pertains to a valgus knee too.  If the big toe isn’t firm to the ground and we don’t have competent arches then the knee may collapse in.)

The keys to the knees.

What’s the solution?

Often someone with knee pain has been told they need to strengthen muscles around the knees namely the quadriceps.  This was the thinking for years.  So people did knee extensions.  The muscles near the knee definitely got stronger but that didn’t improve the walking, running, or stepping pattern that was causing the pain.  Now we understand that the glutes have more influence over the knee than the muscles surrounding the knee.  The pattern of movement is the key factor.  It’s how we use our muscles! We must become aware of how we move, and aware of how we employ our muscles during movement. If we gain awareness of the glutes then we can start to control the knee.  Strength isn’t the main issue.  (The same can be said for the deep core muscles and back pain.)

We need awareness before we can get strong, fast or powerful.  In fact, if we’re not moving well–if we’re not aware of how we’re moving–and we add weight or speed to the scenario then we’re marching headlong into dysfunction, pain, and poor performance.  It’s analogous to hammering a bent nail.  The harder we pound the more it bends and we’re headed for trouble.

Awareness for performance: the bench press

I spoke with a friend and former client of mine who’s learning to bench press.  (My ego demands that I tell you he lives in another state which is why he’s working with a different trainer.)  He told me he learned to use his lats for the bench press. (Think of trying to bend the bar into a horseshoe.)  Now, with the lats engaged he’s got a stronger foundation from which to press.  He’s called in more muscles to help disperse the work.  His shoulders are more stable. Now he can get stronger and likely avoid injury.  Awareness should come first.  (I wish I were aware of all this stuff when I was training him!)

Beyond this example, Louie Simmons in the Westside Barbell Squat and Deadlift Manual directs lifters to identify their weakness–become aware of them in other words–and work to shore them up.  He says don’t necessarily do the exercises you like.  Do the exercises that work for you.

Awareness for performance: running

First, all the stuff above about glutes and knees pertains very much to running.  Remember that.  What else should we be aware of while running?  Think about where your foot lands.  Does it land way out in front?  It shouldn’t.  If it does you’ll likely have problems.  Rather, the foot should land just barely out in front of your center of mass and the foot should land right below the knee, not out in front.  If you watch recreational runners you’ll often see the foot land out in front. Watch elite runners and that foot lands very close to right underneath.  Think of your leg as a swinging pendulum.  If the pendulum swings wide then a) your foot lands out in front, b) your cadence is slower and c) it’ll take more energy to run.  In a better situation you’ll swing your pendulum/leg in a shorter arc.  The foot will land closer to you which will result in a faster cadence and you’ll be more efficient.  You’ll be faster and you’ll be in a better position to avoid injury.  For more on this and further awareness of how you should run, check out this very informative article by Jay Dicharry, author of Anatomy for Runners.

Awareness for weight loss

So we’ve discussed awareness as it pertains to pain and performance.  Where else does it matter?  Do you want to get leaner and generally healthier?  Then you better be aware of your eating habits.  Very similar to poor movement patterns, poor eating habits will over the course of time do great damage to our physique and overall health.  The problem is a habit is an unconscious thing.  We’re not aware of our habits!  We eat mindlessly in front of the TV.  We’re caught without healthy food to eat so we resort to fast food or packaged frozen dinners.  We take nibbles of junk snacks thinking that we’re not eating that much garbage, but by the end of the week we’ve consumed a lot of crapola.  The result?  We look and feel like a sick, sluggish mess.  What can we do?

Keeping a food journal is by far one of the most effective and cheapest things you can do to help become aware of your eating habits.  You can use any notebook.  Or you can use an online program such as MyFitnessPal.com.

Does this sound inconvenient?  Writing out 1/2 cups, tablespoons, grams, etc. can be a hassle. Guess what.  You don’t have to employ painstaking detail to get the benefits of keeping a food journal.  You don’t even have to track every meal every day.  If you eat some M&Ms, write “M&Ms.”  If you eat a salad write “salad.”  If you can only manage to track breakfast three days a week then that’s better than tracking nothing at all.  The point is to start to become aware of your eating habits.  Any progress at all is progress.  Awareness must come before you can expect to see change.

Awareness elsewhere in life

How are you handling stress?  What time do you go to bed?  If you’re trying to get in shape or you’re training to compete, you better know these things.  If you’re aware of your workouts but your not aware of how you’re resting then you’re compromising your ability to lose weight and compete.

Hard exercise is stress.  So is work.  So are some of our interpersonal relationships.  Alcohol and sugary foods cause stress.  The winter holidays are full of stressors.  If stress goes up in one or more areas then it must come down in others.  Otherwise you’re courting illness, injury or at the very least extreme fatigue.  If you’re feeling pulled in 100 directions then it may be a good idea to scale back your workouts a little.  Don’t give up though!  Recognize that more/harder exercise won’t help you if you’re highly stressed.  Finding some way to decrease some of your stress is critical to good mental and physical health.  Take stock of these things.  Be aware of what’s going on in your life.  Then you can take measures to manage things.

Training Update: I’m Running Well.

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My training–particularly my running–is improving very nicely.  I’m getting faster and I’m able to run without pain far more than I’ve been able to in roughly a decade.  I think several factors are at work here:

1)  I’m using my glutes: I’ve mentioned recently (here and here) that I’ve learned a tremendous amount of how to use my glutes to both stabilize my knees and propel me forward.  This has been a huge bit of progress for me.

2)  I’m aware of my arches:  I recently stood on a device called a pedobarograph.  Quite interesting.  It showed me pressure was distributed through my feet as I stood on it.  Turns out my arches were a bit collapsed.  It wasn’t anything terrible but something worth working on.

I’m an advocate of minimal shoe running so I didn’t want to turn to an orthotic insert.  I did a bit of research and found a tremendously helpful article about the three different arches of the feet–not just the one arch most of us think of.  The article described where each arch is on the feet and how to move and perceive the arches.  Unfortunately, the article and the site it came from seem to have vanished from the universe. I plan to do a video demonstrating where these arches are and how to move them.  The video in the next paragraph should be helpful as well.

3)  I’m toeing off:  Along with using my arches, I’m also focusing on using my big toe to help propel me forward.   It’s the last thing I feel on the ground as I drive forward.  I’ve realized that in past years I haven’t been doing a very good job of this. This is a complex thing.  Here’s a video from the Gait Guys that touches on the muscles and the actions that are responsible for good toe and arch mechanics.  (BTW, the Gait Guys put out a lot of detailed info on all things pertaining to gait.  They can also be found at Youtube.  If you’re having problems with your feet, knees, hips, etc. you may find their information very helpful.)

The video is a bit technical but the long and the short of it informs me that the exercise known as the calf raise or heel raise should benefit me.  Specifically the heel raise should help condition the muscles that maintain the arches in my feet (the flexor hallucis brevis, the abductor hallucis, and the tibialis posterior) I’m doing a lot of these daily in the 15-20 rep range.  I’m also jumping rope.

4)  I’m lighter and stronger: I’m under 200 lbs. for the first time in about 10 years.  Less of me always makes running easier.  It’s also a big help in mountainbiking.  Not only am I lighter but my numbers in the gym are pretty decent being that I’m running and biking a lot.  I power cleaned 175 lbs. recently.  My squat is around 225 lbs. for 2 reps (I’d really like to get that number up….  some day).  My deadlift is about 335 lbs. for 2-3 reps.  My pistol squats are improving in terms of range of motion, reps, and technique.  Stronger + lighter = better.

5)  The FIRST plan is working:  I “first” used a Furman Institute of Running and Scientific Training (FIRST) run plan for the Cherry Blossom 10-Miler several years ago.  It was the best race I’ve ever run so I figured I’d use the FIRST half-marathon and marathon plan for my two upcoming races.I like these plans because they have me running only three days per week.  I’m doing a speed workout on the track, middle distance “tempo” run, and a long run.  I’m doing other things on other days of the week, typically lifting and/or cycling or just resting.  Three runs per week is quite a bit less running than is advocated by other plans.  For an explanation of the plan, have a look at Training Science.com.

6)  Beet juice(?):  I’ve mentioned the benefits of beet juice.  Now, I never attribute one outcome to only one factor, but every time I drink beet juice before a run I feel really good.  I go (for me) fast and I’m able to cover (for me) long distances while feeling quite decent.Perhaps this is a nonsensical placebo effect, it’s all in my head and purely psychological.  Guess what: Who cares?  If I think it makes me a better runner then it’s probably making me a better runner.  Hooray for me and my brain.  We shall choose to be happy.

Fairly Profound Stuff: How to Stand

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Dr. of Physical Therapy Kelly Starrett continues to put out very useful information via his site MobilityWOD.  Torque and Trunk Stability Part I: How to Stand is a recent post.  It discusses trunk and hip mechanics with regard to standing. Does this sound to simple a topic?  Standing?  Perhaps not.

As I’ve mentioned before (here and here) we often don’t walk very well. Strangely, it’s not uncommon for us to stand incorrectly or less than optimally.  As with walking, it so happens we stand a lot.  And if we’re doing it improperly then we very likely are moving toward injury and pain or at the very least, poor performance.

The themes in this video appear in a lot of other MobilityWOD videos (like this one on the set up for the deadlift.)  The concepts of trunk stability via glute and abdominal contraction are hugely important.  As is the idea of torquing or twisting the legs out in order to create stiffness through the legs and hips.   (Similarly for the upper body it’s a good idea to torque out or externally rotate the arms during pressing movements.)

I’ve been using these concepts in my own workouts as well as with my clients and I’ve seen some very good results: more strength, less knee pain and instability, better overall technique.  All of this is good.

If you’re one of my clients then this stuff is homework. If you’re not one of my clients but you want to perform better.  Go ahead and make it homework anyway. See if it helps your squat, deadlift or sitting to standing from a chair–or the ground preferably.