How much do you know about the ITB?

If your first question is “what on earth is the ITB” then this post is definitely for you. Even if you feel you are all over it then you may be surprised there are a couple of quirky things about the ITB that people often overlook.

1. Firstly the ITB or Iliotibial band is a band of connective tissue that runs down the side of your leg.\. It is notorious for being very painful to the touch, especially when getting it massaged or foam rolling it. It can also cause pain in the outside of the knee and hip and can be one of the most obvious causes of pain in this region. It often gets really tight from things like running, cycling and jumping as it works to stabilise the hip and knee. It can also tighten up from lots of sitting and inactivity as it is a hip flexor and if you sit all day you basically shorten up the front/side of your hips.

2. The ITB is also known as the ITT or Iliotibial Tract (mostly Americans because they like to be different). More technically it is known as the Fascia Lata (not Cafe Latte). Fascia Lata basically means the lateral fascia. So the ITB is technically a thick band of fascia ( white connective tissue) on the outside of the leg. We have heard it incorrectly called the ITV or IBT. These are incorrect, but we know what they meant.

3. The ITB is important for stabilising the hip and knee joints.

4. The ITB is NOT a muscle. This is the most common myth you will hear about the ITB. Remember it is a band of fascia (the fascia lata). If you look at a muscular system poster or muscle anatomy book/app you will see that muscles are red (get lots of blood), whereas fascia, ligaments and tendons are white (not great blood supply).

5. The ITB is really like a big tendon from 2 muscles and it can be broken into 2 parts. The anterior (front) part and the posterior (back) part. The TFL or Tensor Fascia Lata (anterior) and the Glute Maximus (posterior) . The Glute Max has lots of attachments at the origin (the part of the muscle that doesn’t move) such as the pelvis, sacrum and Gluteus medius. The Insertion (the part that moves is the ITB and the gluteal tuberosity. Depending on what you read, some anatomy books say that around 80% of the ITB attaches to the Gluteus Maximus. The TFL muscle attaches to the pelvis at the origin (the part that doesn’t move), the insertion attaches to the ITB. So you can see both the TFL and the Glute Max both become the ITB.

6. So where does the ITB insert? The ITB inserts to place on the Tibia, just below the lateral knee joint called Gerdy's Tubercle. Just neat the lateral condyle of the Tibia, which is on the outside of the leg, just below the knee, in case you don’t know where the lateral condyle of the Tibial is. It also blends in with the insertion of the Vastus Lateralis which is the outside quad muscle and the connective tissue around the knee. From a fascia perspective the ITB also blends with the Tibialis Anerior and Peroneus Longus muscles becoming part of the lateral and spiral lines respectively. This shows that the ITB is heavily involved in lateral knee stability and also rotation of the tibia (lower leg bone) and knee joint.

7. What does the ITB do? As it attaches to the TFL and Glute Max it does these actions. Most notably internal rotation of the hip, hip flexion, abduction of the hip (lifting your leg out to the side). It also provides lateral hip and knee stability, especially when the leg is straight or the knee is bent up to 30 degrees. Meaning your hips and knees don't move out to the side when you are walking, running, jumping or doing anything where you knee is under load such as squatting, getting out of a chair, walking up and down stairs and pretty much everything you do.

8. Can you stretch the ITB? Well it depends who you ask. In one study they found that the ITB may only stretch as far as 2mm. That is not very much. And being quite elastic, even if you get that 2mm out of it, it will likely go straight back to where it was. The classic ITB stretch looks like a ballet type stretch (image on your right).

This is a great side line stretch of the body and I think it should be performed by most people regularly to open up the side of the body as we side slumped most of the time. But this stretch wont have very much effect on the ITB. The reason is because there are certain areas of the body where it is really hard to take the attachments away from each other. This is the essence of any stretch. In the case of the ITB it has attachments at the TFL and Glute Max which have different ways to stretch them. And then the attachment at the tibia requires you to bend the knee to at least 30 degrees to put more tension on the ITB. Most people wont or cant bend their knee in this position whilst stretching their leg across the other side of their body. The closest thing you can get to this stretch is the OBERS test, which is a test for ITB tightness we do in clinic. So the best bet for stretching the ITB would be to have someone else stretch you on a massage table. The stretch below is one of the better ITB stretches you can do yourself. This stretch works to stretch the TFL component of the ITB mostly. Try not to over extend your lower back like it is in the photo as this will take some of the stretch off the TFL. The glute max wont be stretched in this position. Use the bottom leg to push the top leg down.

This is a better stretch (below) for the Glute max component and the ITB in general. Click the link to go to the video. You have to lie on a bench with the leg you are going to stretch off the bench with the knee bent. Tuck your bum under to flatten your lower back, internally rotate the foot inwards and also pull the toes towards your body (don't point them). Raise your arms above your head. This doesn't really seem like an ITB stretch if you are used to the ballet style stretch, but if you try it you will see that it really does get into the knee. The key with any ITB stretch is to bend the knee. The ballet style stretch doesn't do this

10. What can we do for a tight ITB? Well, the reality is that the ITB is supposed to be tight. Imagine the ITB is like a leather belt running down the side of your leg or a really strong, super elastic band that may stretch slightly but will snap straight back into position when you stop stretching it. Remember that the TFL muscle tenses the fascia lata (the ITB) so this muscle tenses or tightens the ITB so it can stabilise the knee and stops it moving laterally or outwards. That is what it does. So if we want the ITB to be loose then we wont be able to walk, it wont provide this function and will cause knee stability issues. Remember that there is a difference between tightness and pain. If you are feeling pain around the outside of the knee it may be from friction of the ITB running on the lateral condyle of the Tibia. The ITB can become over tight so releasing of the TFL and Glute max are the biggest muscle releases for impacting the ITB. You can also foam roll the ITB (this can be a very controversial topic amongst practitioners and experts) but if you have lateral knee pain and roll the ITB you will be surprised at how effective it can be. The ITB is supposed to be a very strong and tight structure. It is said that the forces the ITB can take before it even stretches a few millimetres would be the equivalent of town a truck with the ITB. That is more than you would ever be able to roll or stretch. When it comes to stretching the ITB is a tricky area. You can stretch the TFL and Glute max once again in the stretches shown. Do you think this could stretch very much? Not really. And I reckon you could probably tow a car with a leather belt and it wouldn't stretch very much either.

11. Should I foam roll the ITB? As I mentioned above this is a case by case basis but can be a very effective pain management technique. Another factor here is that the ITB sits right on top of the Vastus Lateralis muscle (the lateral quad). This muscle is also very painful and involved in many lateral knee tracking issues. So rolling what you think is the ITB is more likely the Vastus Lateralis. It will still be helping you, but it won’t be the ITB you are effecting with the roller. Remember that pain is a very complicated issue and often it is more the neurological change we are creating when we do things like massage, stretching and foam rolling, rather than the old fashioned idea that we are literally lengthening the muscles. If you are foam rolling the ITB try to bend the knee to 30 degrees while rolling on it to give it extra stretch. You can also try bending and straightening the leg whilst holding pressure on the ITB.

12. Another factor if you are having issue with your ITB is to look at glute strengthening. As, if the glutes are weak or inhibited (not working very well) then the TFL can become overloaded and the ITB will tighten. Therefore strengthening the glute max, med and minimus will help offload the TFL and also provide more lateral stability in the hips and knee. Strengthening the Quads is also a factor here. Obviously this is on a case by case basis as different injuries will respond differently so please take this as general advice and get it checked properly if you are in pain.

13. I have seen people who have had such severe tightness in the ITB that they have had it surgically lengthened. This is a very aggressive and risky way of treating lateral knee pain and should be the very last resort after lots of conservative treatment and self management has been undertaken. The surgery is not always effective, so you can still end up with pain that may even get worse.

14. There are many injuries involving the ITB. The most common is ITB friction syndrome. This is thought to occur from the ITB rubbing on the lateral condyle of the tibia. Whilst this makes sense the jury is still out as to whether this is the actual cause of the lateral knee pain. The common treatment is stretching and foam rolling of the ITB, but as we have established these can be tricky things to do and remember the ITB doesn't really stretch.

Patella tracking issues have been linked to a tightness in the ITB and lateral quads pulling the knee cap out of alignment in the joint.

Also lateral hip pain known as Greater Trochanter Pain Syndrome has been linked to ITB tightness. Common exercises that injure the ITB or lateral knee are running, cycling, weightlifting especially squats, jumping, skipping and most exercises that involve bending of the knee.

So there you have it. Just when you thought you knew something about the ITB there is always more to know. The big takeaways here are that the ITB isn’t a muscle, it is a band of fascia. It is supposed to be a rigid tight structure. The TFL and GLute max are the muscles that control the ITB so working on those muscles will give you more bang for your buck than purely hammering the ITB, which is most likely the vastus lateralis muscle anyways. There are some effective rolling techniques and stretches but we feel that the best way to have the ITB released is to have a professional work on it as well as perform a thorough assessment to get to the source of why this issue is happening in the first place. Treatment techniques such as Dry Needling, Active Release Techniques and myofascial release can be very effective at treating issues and injuries of the ITB. As always we love your comments so please feel free to get in touch. If you require help with your injury then we are here to help.

Refernces

- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5294943/

- http://www.kneeclinic.com.au/knee_exam/examination_knee/page09.htm

- https://b-reddy.org/the-best-damn-it-band-stretch-ever/

- https://keyassets.timeincuk.net/inspirewp/live/wp-content/uploads/sites/2/2014/03/Foam-roller-IT-band.jpg