The Iliotibial band - over-diagnosed, under-treated...

March 30, 2017

What is the iliotibial band?


The iliotibial band (ITB) is a structure that runs along the lateral thigh, from the iliac crest to the lateral condyle of the tibia. It's functions are to assist in stabilising the lateral knee, and through the muscles that attach into it it extends and laterally rotates the thigh. 


It has an important role as part of the 'lateral sling', where along with other structures such as the tensor fascia latae (TFL) and the gluteal muscles it assists in pelvo-femoral stability during movements including walking, running, lunging and climbing stairs. 


The ITB itself is a portion of dense fibrous connective tissue, that arises from a thickening of the fascia lata (the fascia lata is a deep fascial layer that covers the entire thigh musculature from your pelvis to your knee). The ITB itself actually extends towards and attaches directly onto the femur to form separate compartments for the muscles of the thigh.


Deep fascia itself has very poor extensibility, compared to superficial fascia, but does have a large proportion of sensory receptors that detect the presence of pain, movement, pressure, vibrations etc. Although there is an idea that deep fascia can contract, the ITB itself doesn't contract enough on its own to create the movement it does. So, how does the ITB contribute to movement at the hip and knee? The ITB is strengthened posteriorly by acting as an attachment site for a portion of fibres from the gluteus maximus. It also is the distal attachment for the muscular fibres from the TFL. This allows the ITB to assist in hip extension, abduction and lateral rotation. 



Why do I think that the ITB is over-diagnosed?


I frequently hear, be it in the clinic or in the gym or at sports clubs or from friends, that they've been told that their ITB is 'tight'. A lot of the time this 'diagnosis' is followed up with a prolonged battering (or 'stripping') along the length of the ITB with little other treatment provided. The treatment is then followed by advice that generally consists of trying to stretch the ITB or foam rolling it in a similar and just as brutal way as the massage they just received. 


I am not disputing the existence of conditions such as ITB syndrome, that leads to lateral knee pain. My issue is with practices that focus on the ITB itself and do not attempt to resolve anything that may be contributing to why the ITB is 'tight' or resulting in repetitive irritation over or around structures of the lateral knee. 


It is becoming more and more noticed that deep fascial structures themselves can't be influenced by manual therapy particularly well, especially structures such as the ITB and plantar fascia. Even with the relatively recent shift in thought that direct treatment to the ITB is ineffective, it is still very common.



Why do I think direct treatment doesn't work?


The reason I don't think you can particularly influence the ITB itself with direct treatment stems from my studies. I would say most, probably all, of my tutors sided on the idea that direct treatment to the ITB was ineffective. However, it was during one time in a dissection room with an anatomy tutor who explained that the ITB has been known to be so tough during dissections that it can actually blunt scalpels... This to me showed how tough it really was, and made me think about whether digging your thumb, elbow or foam roller into it is going to lead to anything but pain!


Further studying showed that the fact the ITB attaches directly onto the femoral shaft itself means that stretching it is going to pretty ineffective. A good analogy for this that I read was if you imagine nailing a length of car tyre to a plank of wood and try and stretch it. It'd be pretty much impossible... There is an idea that the ITB has a viscoelastic property to it, that may lead to some very short term changes that can lead to a very mild lengthening of its fibres. However, this would be quickly reversed. So even if you used this theory as a basis for direct treatment to the ITB, the chances are that by the time the patient has got back home then everything would have reverted back to their previous state. 


So how can you actually treat the ITB?


Basing your treatment on a basic understanding of anatomy will help. The direct influence that the ITB has from both the TFL and gluteus maximus means that there is a very strong likelihood that these muscles are leading to the feeling of the ITB being 'tight'. If they are not functioning correctly, be it due to general tightness or the presence of 'trigger points' among other things, then addressing these issues will probably have a much more profound affect than smashing the ITB directly over and over again...


There may be more to the symptom picture though than just a tight muscle... Poor biomechanics when running, squatting, lunging or even just walking may place the lateral sling (mentioned above) under greater strain most likely leading to dysfunction or tightness in the gluteus maximus and/or TFL. These poor biomechanics may even be due to poor gluteus medius or minimus strength resulting in excessive hip adduction that again puts the lateral sling under strain.


It may be a case to look more globally through the body during your examinations as a practitioner, or assessing your own movements. For example, looking at the link between your gluteus maximus and its role in the thoracolumbar fascia means that issues in or around the lower back may have an influence through myofascial chains to the ITB. Dysfunction in the foot leading to over-pronation may lead again to excessive medial rotation or adduction of the hip that may again lead to excessive strain through the lateral sling. 


So what does all of this mean?


Trying to remain as open as you can to the entire body and the inter-relation of it's various parts in order to understand any underlying contributor. It's finding these underlying problems that is the difference between short term and long term recovery from conditions.


One of the first concepts in anatomy that I was explained to me during my degree, was that of 'Tensegrity'. The idea that the entire body is an inter-related three-dimensional structure that contracts, relaxes, lengthens and shortens structures as one unit. Isolating structures of the body during manual therapy is an out-dated approach.


Remember that the body is more than just the sum of it's parts.






If you want to book an appointment to see one of our Osteopaths then please call 020 8304 7237. Or if you have any questions please give us a call or contact us on Facebook or via email.


This blog shouldn't be used as a replacement for seeking medical advice from a qualified health care professional. 




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