To roll or not to roll the Iliotibial Band, that is the question…

I am asked almost weekly whether or not rolling out their iliotibial band helps with lateral thigh pain. This phenomenon is been around for quite a long time. People get iliotibial band syndrome (or IT Band syndrome) and someone along the way (a trainer, coach, significant other, Grandma at Christmas dinner) tells them that they should roll out their IT band on a foam tube. The typical patient tells me that they have been doing this for months and it provides some relief but it always come back. During this time, the patient feels that they are being proactive in managing the pain, but after awhile is exasperated and wonders why their IT Band are always tight and not healing ; and likely getting worse.

Lets ask the obvious question… if the patient is healthy, why aren’t they healing? There is this idea that tissues just go bad. That is false. There is no mysterious IT band disease that affects millions of people a year. Tissues degrade if they are overused and aren’t given the appropriate time to heal up. Under most circumstances, when a tissue is used it responds with conditioning response that helps it tolerate increasing amounts of stress the next time, (assuming appropriate and responsible increases in exercise intensity are being followed). This results in a net loss of tissue regeneration leaving the person worse off than when they started. If there was no traumatic history to the tissue, there has to be a micro-repetitive trauma that is accelerating breakdown during use therefore not allowing the tissue to heal.

Is it the IT band, something else, and what causes it?

I greatly question whether the Iliotibial Band is really the issue; this is tissue that is built for abuse. There has been little research done on the tensile strength of the IT Band; how much stress it can take before it deforms permanently or breaks. It makes sense, it is hard measure this in real live human subjects and cadaver (dead) tissue skews results. Suffice to say, a 1931 study by Gratz et al. examined cadaveric fascia lata tissue and reported that 8-10% elongation would lead to a structural “break”. Gratz likened the tremendous tensile strength of the fascia lata to “soft steel wire of similar weight”, yet with “unexpected degrees of elasticity”. More recent studies have shown that there is some elongation of the IT band; Falvey et al in 2010 showed that the IT band elongates ~4.75% near the hip and around 1.7% down by the knee. But let’s’ be honest, what we are dealing with here is some tough tissue that resists deformation, stretch and will not break easily. So what gives?

Having worked with many patients on the issue, there appears to be a common thread between them: considerable hip muscle weakness and loss of internal rotation on the painful side. When attest the hip muscle strength on the painful side there is a considerable loss of hip strength. I believe that this is leading to a process called quadricep dominance. Quadricep dominance is when the quadricep muscles are considerably stronger than the reciprocal hip muscles. Think of it this way, your butt muscles push you when you walk and your quadricep muscles pull you. If the patient is not getting there “full push” than they have to be pulled more.

Patients often tell me that they have been doing a lot of gluteal muscle strengthening exercises and cannot believe how weak they are. Where is this weakness coming from? Another common thread is a lack of hip internal rotation which I believe leads to some latent back issues. Decrease in hip extension and internal rotation causes the spine to have to move more leading to more breakdown and nerve irritability. Once we do some spinal mobilization we show that the patient actually gets a little bit stronger due to improvements in motor control. This incriminates the spine. It’s not uncommon that patients tell me they’ve had on and off low back pain but never enough to do anything about it.

Weak hip muscles leads to accelerated mechanical breakdown of the quadricep muscle. Very often when I am pushing around on the lateral thigh, I’m not pushing on the IT band and creating pain I’m pushing on the lateral quadricep. This is because the patient is getting muscle trigger points along the lateral quadricep. Muscle trigger points are balled up muscle fibers that are caught in a contraction and cannot let go. This leads to a decrease in blood flow in and out of that muscle tissue leading to burning in pain. When you roll your IT band, (and the underlying lateral quad) it helps circulate some of the blood out of that tissue and allows little bit back in which produces a small amount of improvement. But without getting that tissue to release, it remains chronically painful.

Iliotibial band syndrome is more complex than just rolling out the lateral thigh and hoping for the best. I typically will treat this patient with spinal and hip mobilizations, dry needling to release the active muscle trigger point and then start with hip stabilization and strengthening. Typically we have our patients up and running in 4-6 weeks.