This blog discusses current trends around the treatment of runners with ITB pain and does not constitute medical advice. If you have knee pain (or any pain for that matter) associated with your running activities, please consult with a clinician for a proper assessment.

The Iliotibial Band (ITB) Demystified:

Treating IT Band Syndrome


In Part II of this two-part blog series, Dr. Jeff Moreno breaks down the 3 different treatment phases of ITB Syndrome so you can get back to running and stay injury-free! Check out Part I to learn more about some of the symptoms and causes of ITB Syndrome.


Think About Healing A Scab

If you want a tissue to heal you need to stop picking at it – it is really that simple. This requires finding a training load appropriate for creating positive growth, but without continuing to compress and irritate the tissue. The tissue will heal if you give it the opportunity, it just needs a little room to breathe.


What’s Your Run Signature?

The risk factors identified in Part I of this blog can be overwhelming, but let's simplify this into three common patterns that increase ITB load during running. This is not an exhaustive list, but a useful guide to many when trying to understand and eliminate the cause of ITB pain.


1) The Sinker     –     2) The Backsider     –     3) The Crosser

Each of these very common patterns significantly accentuates the compressional load contributing to ITB pain. The phases of treatment outlined in this post, including drills and gait-retraining, are designed to bring attention to and override these tendencies over time.





1. “The Sinker”


Running fundamentally requires resisting and overcoming the effects of gravity over many strides. Sinkers have difficulty dealing with gravity, seen in a dramatically sinking hip.









2. “The Backsider"

Every running stride passes through distinct frontside and backside phases. Backsiders spend a disproportionate amount of time in the backside phase (everything behind the body), increasing ITB loading and contributing to pain.








3. “The Crosser”


Crossers are characterized by excessive movement of legs toward the body's midline. The resulting narrow splay increases ITB strain and, especially with large spikes in training load, can cause ITB pain.







TREATMENT PHASE I

Discover Current Load Capacity3

The ultimate goal is to address the root cause of your ITB Syndrome through proper load management.
  • Always keep moving, but keep pain less than a 3/10 with ALL daily activities.
     
  • Gradually add volume in order to maintain fitness, as long as pain remains less than 3/10.
     
  • This means running may need to temporarily cease in favor of some alternatives:
     
    • Walking: uphill (consider using a treadmill), 5%+ incline, making sure to keep strides small. Perform 5-7x/wk with a duration that produces minimal to no pain.
       
    • Cycling: high RPM and allowing for the maintenance of fitness levels.
       
    • Swimming: with a pool buoy between the legs (to minimize pain associated with kicking), IF you are going to swim. Note, however, that swimming eliminates gravity in a sport that requires runners to tolerate significant peak loads due to gravity, and that swimming isn’t the best option.
       
    • Low-load hip & glute exercises: to fatigue and with variety:
      • On the table (basic)
        • Ex: Side Plank
      • Upright single leg support with triple flexion (single leg control/balance)


Progress to PHASE II when there is no pain while walking on any surface or terrain




TREATMENT PHASE II

Add Dynamic Load


Running requires the ability to resist and then overcome the effects of gravity on one leg over time and distance. Incorporate running movement exercises that will help to improve the lower body’s capacity to deal with the stress of each step during your run (especially if you're a Sinker!).

  • Heavy Slow Resistance (HSR) training2:
    • Master your movements
      • Squat! Fundamental movement that everybody should maintain


      • Single leg posterior (backward) step down (off 6-8”step) to triple flexion 


      • Single leg anterior (forward) step down 


      • ½ Kneeling to Stand (hip lock position)


    • Set your routine
      • Consistently incorporate HSR training 2-3x per week.
      • Control the tempo: aim for a slow down-and-up lasting 5 seconds.
      • 3 sets of 10-15 reps (starting with body weight), progressing to 3 sets of 6-8 reps with a weight that creates near-muscular failure on the last rep.
      • Emphasize progressive loading: the weight should go up as you adapt.


Progress to PHASE III when you can complete the Running Readiness Assessment without pain




Running Readiness Assessment

  • All activities of daily living without pain.
  • Walking an hour and a half or more without pain.
  • Jog in place 1min x4 without pain.
  • Single leg step down (forward or back): 3 sets of 15 reps forward and back without pain.



TREATMENT PHASE III

Return to Running


A) Running Form Drills

Attention to quality of movement is important in the development of any athlete. Pay attention to your posture during drills to set the tone for your running.
  • Plyometrics2
    • Improve the elastic return of energy and emphasize vertical force into the ground in a short amount of time.
    • One of the most basic and easiest forms of plyometrics to start with is skipping.
    • A Skip: before every run, 3-5 reps of 15 meters 


  • Single-Leg Switching (1 & 2x)


  • Ankle and Calf Dribble: 3-5 reps of 15 meters



B) Gait Retraining – Start With Cadence

Incorporating better habits during the return to running will increase resiliency moving forward. The most accessible and achievable form of retraining is to increase your cadence.

  • How to Get Started
    • Most GPS trainers & smartwatches (and PWR Lab!) display average cadence
    • Look back at a recent run on typical terrain and make note of your cadence
    • Focus on slightly shorter, faster, more vertical steps during your next run
    • Target a gradual 5-10% increase from your current cadence
    • Example: Try to increase an average of 78 strides/minute (156 steps/minute) to somewhere between 82-86 strides/minute
       
  • Documented Benefits
    • Reduced strain at ITB1.
    • Improves pre-activation of lower body muscles to prepare for ground contact.
    • Decreases stride length at a constant pace/speed.
    • Reduced hip adduction and knee flexion during stance.
    • Reduced load at the knee (PFJ), and peak muscle forces for the calf, quads, and glutes (this means less work for those muscle groups).
    • Reduced stress at achilles, shin, and plantar fascia.
    • Improved running economy5.

C) Start Running

  • Start by running a total of 3-6km per week, broken into 3 sessions
    • Volume can vary depending on running experience and current capacity.
    • If starting from nothing, start with a walk/jog mix – be conservative.
    • Slight uphill preferable.
    • NO downhill running for the first month while increasing running-specific load.
    • Ensure pain is less than 3/10 during a run.
    • No pain should persist once the run is finished.
       
  • Walk for 30-45 minutes on non-running days.
    • It's good for you! And there is nothing more essential in life than being able to walk.
       
  • Increase total weekly training volume by 10%-30%4.
    • This is where PWR Lab becomes your best friend.
       
  • Adjust training priorities
    • In order: Recovery > Consistency > Frequency > Volume > Intensity.
       
  • Monitor symptoms, workload, and progress consistently for the first 1.5 months.
    • This is the highest-risk window. Be conservative and patient for long term results.
       

PWR Lab Keeps You On Track

ITB Syndrome is load capacity issue, and often accompanies a large spike in training load. Sign up for a free trial of PWR Lab today and experience firsthand how easy it is to monitor your load, and control your ramp up as you return to running.

Keep your bars green, and take advantage of your PWR Lab Dashboard to predict risk, prevent injury, and perform optimally.


References

  1. Boyer ER, Derrick TR. Select injury-related variables are affected by stride length and foot strike style during running. The American journal of sports medicine. 2015;43:2310-2317
  2. Blagrove RC, Howatson G, Hayes PR. Effects of strength training on the physiological determinants of middle and long-distance running performance: a systematic review. Sports Med. 2017.
  3. Cook JL, Docking SI. “Rehabilitation will increase the ‘capacity’ of your… insert musculoskeletal tissue here….” Defining ‘tissue capacity’: a core concept for clinicians. Br J Sports Med. 2015;49:1484–1485.
  4. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med. 2016;50:273-280
  5. Quinn TJ, Dempsey SL, LaRoche DP, Mackenzie AM, Cook SB. Step Frequency Training Improves Running Economy in Well-Trained Females Runners. The Journal of Strength & Conditioning Research. 2019.
Dr. Jeff Moreno
About Dr. Jeff Moreno

Jeff, co-founder of PWR Lab, is a Doctor of Physical Therapy and Board-Certified Orthopedic Clinical Specialist. Passionate about running and playing, Jeff fundamentally loves people and movement of any kind. He strives to raise the bar in sport by finding ways to proactively prevent injuries and prioritize the long term development of athletes. He has been successful in employing a data-driven, hands-on approach to physiotherapy with National, World & Olympic Championship medalists in Track & Field from USA, China, Canada, and Mexico as well as many NFL, NBA, MLB, NHL, Judo, and Triathlon athletes