Written by: Lewis G. Maharam, MD
Symptoms: Pain on lateral side of knee or hip a mile or two into run. Never have pain from first step.
How it occurred: Friction of tight iliotibial band rubbing at hip and/or knee.
What the doctor may do: Palpate ITB. Gait analysis for overpronation. X-ray and MRI not needed.
Getting back to running: Stretching. Foam roller. “The Stick.” Orthotic or orthotic adjustment. If a small bursa has formed around Gerdy’s Tubercle, cortisone injection into the bursa. PRP if cortisone is ineffective. You can run through IT pain as long as it does not change your running form.
NOTE: Surgery should be last resort. In all my years of practice, I have seen only one case that required surgery to remove the bursa around Gerdy’s Tubercle.
Iliotibial band syndrome, also called ITB friction syndrome, inflicts sharp knee or hip pain on a wide range of sufferers: ballet dancers, football players, and—yes—runners and walkers. Brought on by a sudden increase in training mileage or even a single unusually long workout, it’s nothing more than an irritation of a band of connective tissue that goes from the hip (the iliac crest) to the shin bone (the tibia). Hence, iliotibial.
The band could go about its business of stabilizing a runner’s foot during footstrike if only it didn’t have to pass over two impediments—a bony projection (called Gerdy’s tubercle) on the outside of your knee, and another diffuse bony protuberance (which has no name) on the hip—every time your leg is bent and straightened again. Loose ITBs slide harmlessly past the two obstructions. Tight ones rub against them, get irritated, and react with a sharp pain on the outside of the knee or hip that usually does not become bothersome until a couple of miles into your workout.
In the spring, my waiting room fills with suddenly ambitious spring trainers who find, practically overnight, that they can’t run very far. You can diagnose this from across the room: “Doc, the pain starts a few miles into the run, not at the beginning, and sometimes I wake up with it the next morning after a long run.” They’ve taken a few days off, to no avail. They’ve switched to their bicycles but gotten no relief (they’re feeling the same rubbing during cycling). The really determined ones have scanned a couple of ITB articles, and now they’re sitting there girding themselves for, one, a long layoff; two, a local steroid injection; or, three, surgery. In my opinion none of that’s necessary, though you might not know it from the number of athletes advised to try at least one of the three remedies. Surgery is a last resort, and a long layoff won’t do anything to loosen a tight ITB.
But simple stretching will work wonders, and that’s all the injury usually requires. Whether you were born with an abnormally tight ITB or stiffened it with exercise (the band contains a very small amount of muscle tissue), the key to a cure is to get some slack back into it. Then it won’t rub. Ice and an oral anti-inflammatory will help get rid of the pain, but only a supple ITB can keep the condition from returning.
The simplest stretch is to lie on your back, bring your left knee up to your shoulder, and push your knee over to the right shoulder with the palm of your left hand. Hold for 20 seconds, and repeat five times. Then do your right knee. Do this exercise at least three times a day in addition to making it part of your preworkout routine (yes, you can continue to exercise), and you’ll probably see results in about a week. When the condition clears up, just use the stretch whenever you can; more is better!
There’s a second simple exercise to stretch the band out that I also recommend. Stand at arm’s length from a wall with your feet together. Keeping your feet in place and your arm extended, slowly stretch your hips toward the wall, hold for a few seconds, and then return to a standing position. Turn around, put your other hand on the wall, and repeat. Simple. Do this one often, and you will find the suppleness of your ITB coming along nicely.
For most who have faithfully tried these exercises without relief, stretching is just not enough. A foam roller, which you can get at marathon expos or online, is a good addition to stretch out the band. The roller is nothing more than a short log made of dense, lightweight foam. The roller is about 4 inches in diameter, and all you need to do is lie on it and roll the affected area back and forth on top of it. You can also try “The Stick,” which has a series of small-diameter rollers on a spindle; you grab the stick at each end and roll it back and forth over the affected area. Again, more is better; you cannot do this too much, only too little.
If you are still not better, you may have been blessed with really tight connective tissue. In that case, not only will you need physical therapy, but also some therapy centers now have a new machine called a “Powerplate.” Most professional teams have this gizmo, and some celebrities like Madonna are said to have purchased one. This expensive machine works by vibration while you stretch on it, and I have seen people who were so tight you never thought you’d get them stretched out look like Gumby after four short weeks of stretching on this machine three times a week!
Some people develop what I call an adventitial bursal sac right around Gerdy’s Tubercle. This fluid-filled structure can get inflamed from running; a simple cortisone shot right there has done miracles for some patients. Don’t be afraid of the cortisone, as it stays locally and there are no systemic effects.
Last but not least, when you are running, the ITB stretches when you overpronate and releases (contracts) when your foot is in the air. Just as a stretched rubber band comes back shorter when released, so does the ITB. If you are using an orthotic to correct your forefoot position, and the orthotic is flexible, you don’t need to change it (or them, most likely, because both feet will probably be overpronating). If your orthotic is made of a hard material that ends midfoot, however, chances are you need to get a different one that works while you are running because you spend 70 to 80 percent of your time on your forefoot.
If none of this provides relief, ask your sports physician the following questions:
- Do I really have ITB syndrome, or is it something else?
- Have I developed a new bursa at Gerdy’s Tubercle that would respond to a steroid injection or PRP?
- Am I an overpronator, and are my orthotics correcting for this?
If in fact you do have ITB syndrome, however, and you follow my advice, you will be pain-free within four weeks! Promise.
This article was adapted from the new book Running Doc’s Guide to Healthy Running with permission of VeloPress. From head to toenails, Running Doc’s book explains healthy running practices and guides runners to the right diagnosis and treatment for over 100 running injuries and related health problems. Running Doc’s Guide to Healthy Running is now available in bookstores, running shops, and online. Download a free sample and preview the contents at velopress.com/runningdoc.