Iliotibial band syndrome
by Dan Empfield, 12.9.02

I suppose I could go to prison for this. Mine could be the great test case determining what is preeminent, the laws prohibiting the abridgement of free speech versus the laws against practicing medicine without a license.

I am somewhat of an authority in the area of IT Band syndrome, in the same way that Liz Taylor is an authority on divorce. One could do worse than listen to her advice though it could be construed as practicing law without a license.

Experience is a great teacher, and experience is what I have when it comes to ITB syndrome. But "experience" is that thing you get when you don't get what you want. What I wanted was to run. What I got was four years of experience preparing me to write this article.

I haven't had this problem (the syndrome, not multiple marriages) for quite awhile, knock on wood, but when I did have it, it stayed for a lot longer than I thought it would—more than any other injury I've ever had in any sport. During that period of time I came to the conclusion that my running days were over. I gave up the sport entirely, certain that I would never return to it. And this was difficult, because this is back in the days when I was actually a fast runner. I had run the mile in 4:19 as a 16-year-old high-schooler and the future was bright. Then ITB syndrome struck and, try what I might, I'd run my last klick for the balance of my teen years.

In an effort to keep from ending up behind bars, I shall only tell my own story. Do not try this at home, go see your doctor before entering into any form of fitness program, employees of not eligible to enter, and remember that I'm an experienced test driver on a closed course. In other words, I'm only telling you about my own IT band, I'm not telling you about yours.

The iliotibial band is a long tendon that runs from your hip to just below your knee. It connects to a hip muscle called the tensor fascia lata (the TFL) and the other end connects to your lower leg. It helps performs "abduction." Your wife's leg performs an abduction when you're standing next to her and you say something impolitic. That pain you feel when the side of her foot whacks your lower leg is due to her TFL flexing, and the tendon that is her IT band carries that
"shut up, you idiot" message to a spot down her leg deemed by God and nature to be a profitable place along the lever so as to cause it to shoot straight sideways with maximal force.

She also uses the TFL muscle—and its ITB tendon—when she's laid out on the floor in front of a Jane Fonda workout tape, on her side, head propped up by her hand so as to get a less-sideways view of Jane, while raising her straight leg up into the air. If you're performing abduction properly your entire leg moves as a unit, as the knee doesn't allow the lower leg to flex outward to the side, only backward.

The heck of it is that abduction is of only a very minor use to the triathlete, kinesiologically speaking. Nowhere during the swim, bike or run is one likely to say, "Ahh, yes, my ability to perform powerful and repeated use of my abductors is what got me to the podium today." Yet it's just this damnable tendon that can cause you enough grief to keep you off your feet—or in some cases off your bike—for a long time.

With me, the problem was confined to running. I had no problem riding a bike, cross-country skiing, downhill skiing, and even playing tennis. I could abuse my lower limbs in every conceivable way, and the one and only thing I was kept from doing was the one thing I adored doing above all else.

Furthermore, when I was eventually able to run again, I contracted the darn thing in the other knee. Fortunately that spate of ITB Syndrome was short-lived, and I shall describe my own process of both prophylactic behavior and treatment after-the-fact.

I am an overpronator. I do not know if people like myself enjoy a greater incidence of ITB syndrome than others, but I suspect so. I have little doubt that in my case the problem took the circuitous route of a problematic footfall, thereby wreaking havoc with my hips, at which point my hips said, "back atcha" and returned the package from whence it came. On its way southward the insult found a resting place just at the outside of my knee, on a horizontal plane from the center of my kneecap.

I became an overpronator because I was born that way, or because I spent much of my youth running around shoeless on the beach, like a South Sea native. I spent so much of my youth so-clad that the rubber tire tread on the bottom of a juarache sandal was no tougher than my own foot leather. I suspect that all this unsupported running caused my ankles to cave in to some degree.

Add to this the fact that when I finally did start running serious miles, as a freshman in high school, all of them were run in a paper-thin shoe called the Tiger Marathon, which gave me about as much support as you'd get if you could somehow pull the sock liner out of the running shoes of today and build a shoe around just that.

With a history like that, it's not hard to see how anatomical insults could accrue. Could you blame any joint from giving the rest of your body the proverbial finger, saying, "I'm sore as hell and I'm not going to take it anymore!"?

Regardless of the cause of my own ITB syndrome, here is what I did and continue to do...

• My running shoes always have a sufficient "medial post," that is, they are designed not to cave in on the medial side. Tactics footwear companies employ to achieve this are multiple-density midsoles and outsoles, and various EVA, composite and plastic heel cups that cradle the medial side of the upper.

• I also require that my shoes are designed to easily accept an orthotic. Nowadays my orthotics do not have a hard plastic component. My prior orthotics did, and certain "mocassin-style" or "slip lasted" shoes did not provide sufficient support for the orthotic. This is because the profile of the inside of the shoe in the heel area was rounded, and did not provide a flat surface to meet up to the orthotic's flat surface. Likewise, certain shoes—especially racing flats or very lightweight trainers—are just too flimsy on their medial sides to support an orthotic. If the orthotic can cave a shoe in on the medial side it's no longer doing the job of supporting your arch and the rest of your foot.

• I do as much off-road running as possible. Obviously this is going to be a challenge for certain Slowtwitch readers, depending on where you're located. That said, I've pretty-much always found a way to keep off the pavement, regardless of where I'm at. Whether I'm traveling in New York City, Boston, Atlanta, or just about any other city, there's almost always trails to be found and I don't mind driving a few miles to get to them.

• When I am on the pavement I try my best to keep myself on the level, not on a bias or cant. Roads are made to allow rainwater to run off, and this means they're all slanted. I try to minimize the amount of time I spend on a slant, and I don't run on the same slant for very long. I'll switch from side to side every several hundred yards if I have to, though it is usually optimal to run against traffic for safety reasons. I try to run on rural roads, however, so that I don't have much traffic to worry about.

• I now run with a technique that minimizes stress to my joints. A description of running techniques I employ is found elsewhere in The Long Run, and is basically built around the idea of a somewhat higher cadence than might seem natural, and a footfall that occurs directly below my knee.

• There is a stretch that helps me prevent ITB syndrome, and it is best used by me in prevention-mode. Once I've gotten a full-blown ITB problem going the trick, for me, is to do no stretch that aggravates a tender IT band. The stretch goes as follows. I lay on my side, body straight, facing the edge of a massage table or any other table that will support my body weight. I drop my upper leg off the edge of the table and let it hang by its own weight. In this pose my upper is crossing in front of my lower leg scissors-style. This stretch is non-ballistic and low-stress, as it is only the weight of the leg itself that is stretching the IT band.

• When coming back from this problem it was crucial that I not test this injury. If I felt the pain I immediately stopped and walked. I started back very conservatively. I would run perhaps a mile. That might turn into two miles the next week, and three the week thereafter.

• I also perceived that my IT band was happier if I ran on the back end of a brick. In other words, I might ride thirty or forty miles, and then go into a run immediately or shortly thereafter. My one or two mile "sample runs" might go more smoothly if my knees were warmed up by my prior ride.

• My IT band problems were limited to running. Others have this problem cycling. While I have limited experience with this myself, I can see how, like alcoholism, I could have a predisposition toward a syndrome I don't now have, but certainly could under the right circumstances. I therefore have a very conservative cleat mount on my cycling shoes, which I describe elsewhere. That, plus making sure I don't drink alcohol to excess, or more than four days a week, seems to keep me and my knees on the straight and narrow.