Injuries - Iliotibial band friction syndrome in triathletes

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Iliotibial BandA very informative article on the causes, prevention and treatment of ITB issues. Mike

What it is

The ITB is the connective tissue band that runs down the lateral side of the thigh and attaches on the lateral surface of the tibial condyle (Gerdy’s Tubercle). The ITB originates from the Tensor Fascia Latae (TFL) muscle that originates on the outer third of the antero-lateral iliac crest.

ITBFS is an overuse injury that produces pain on the lateral knee during running and, occasionally, cycling. Pain is generally caused by an unusually tight ITB, the undersurface of which frictions over the lateral femoral condyle. This occurs during knee flexion and extension at approximately 30 degrees knee flexion when running and cycling, when the ITB flicks over the lateral femoral condyle. This process leads to friction, microtrauma, inflammation – and hence pain develops.

What causes it

The two most common predisposing factors that lead to ITBFS in triathletes are anterior hip inflexibility and poor rotational control of the lower limb. First, one of the reasons that this pattern of inflexibility is frequently observed in triathletes is because of the length of time spent cycling with the hip flexed in the aero/time trial position. This prolonged activity in hip flexion can lead to muscle sarcomere shortening – and hence iliopsoas/TFL muscle tightness develops over time. This increased tension in the TFL that is transferred to the ITB can cause increased friction and pathology.

This same flexed positioning during cycling can also lead to the development of reduced rotational control in the lower limb. This can occur if the TFL muscle becomes overactive in the shortened hip-flexed position described above. The TFL internally rotates the hip and is also a synergistic hip abductor with the Gluteus Medius muscle during stance phase, preventing lateral pelvic tilt. Therefore, if the TFL develops overactivity, the Gluteus Medius can potentially become inhibited. This can lead to the lower limb being forced into internal rotation and uncontrolled pronation through the stance phase via the action of the TFL. ITB friction can then increase over the lateral femoral condyle due to this movement.


One strategy essential for preventing this pattern from developing and potentially causing injury is regular hip flexor and quadriceps stretching. Whichever position you prefer to stretch your quadriceps muscle group (standing, kneeling, sidelying etc), keep your knees together and your gluteal muscles contracted to ensure an ideal pelvic and spinal position. The muscle groups should be stretched daily and before and after activity (especially after cycling) to optimally prevent the development of ITB symptoms. As with all stretches, they should be held for approximately 30 seconds without bouncing, performed gently and slowly to the point of tension but never pain.

Self-massage to the outer side of the thigh between the knee and the hip can also assist in reducing tightness in the ITB. Icing the distal ITB is essential after running and cycling for 20 minutes.

Lower-limb stability, strength and balance exercises are crucial in rectifying ITBFS predisposing factors. Single leg squats and lunges can remarkably improve lower-limb control if performed in front of a mirror with good alignment where the knee flexes over the middle toe. This ensures that the Gluteus Medius activates effectively and that the TFL remains underactive.

Assessing biomechanics

Another strategy used in the prevention and assessment of ITB friction syndrome is to assess the triathlete’s running and cycling biomechanics. The biomechanics of the Australian triathlon squad members are routinely assessed by their respective State Institutes of Sport and/or their individual coaches. They are performed via video analysis where coaches, physiotherapists and biomechanists can assess running and cycling technique and prescribe various drills and strategies to aim to rectify any biomechanical flaws.

In conclusion, ITBFS is a complex over-use injury that can be easily treated symptomatically but has numerous predisposing factors that if not addressed will lead to persistence and/or recurrence of symptoms.

Case study

A 35-year-old male triathlete (Olympic Distance) presented to the clinic with moderate right Æ lateral knee pain with a two week history of gradually increasing symptoms. He had never had any lower limb over-use injuries before but had sprained his right ankle many times. His training history showed a steady increase in cycling and running mileage and over the last month he had begun intensive hill work in both disciplines. He commented that his running shoes were reasonably good and that he did not wear orthotics.

His physical assessment highlighted the following factors:

  • Short stocky build with lordotic lumbar posture
  • Increased pronation (Æ > (L)) with walking and running
  • Poor proprioception and control on right side with single leg squat test
  • Weak Æ Posterior Gluteus Medius on modified Ober’s test
  • Tight Iliopsoas & ITB Æ > (L)
  • Tight and tender Æ TFL
  • Tender on palpation of the distal 2-3 cm insertional portion of the ITB over the lateral


The diagnosis was ITBFS caused by an increase in training intensity over last month. An hypothesis as to the potential predisposing factors leading to the injury could be: the past Æ ankle sprains; poor propriception; poor gluteal stability; overactive TFL; tight ITB; microtrauma; inflammation/injury. One cannot exclude the triathlete’s lordotic posture with tight iliopsoas and ITB as a component of injury predisposition.

Symptomatic treatment consisted of:

  • deep tissue massage to the distal half of the ITB;
  • once daily oral anti-inflammatory medication prescribed by GP;
  • topical application of anti-inflammatory gel to tender injured area;
  • application of ice for 20 minutes daily and after cycling.

Essential rectification of his predisposing factors included:

podiatry review and orthotic prescription (Æ > (L) arch support); trigger point releases of TFL and Iliopsoas; stretching of ITB/TFL, Quadriceps, Iliopsoas; proprioceptive training of right lower limb (wobble board/single leg stance); stability training with single leg squats (shoes on with inserted orthotics).

Training modification consisted of:

  • no running for two weeks;
  • maintain cycling mileage with reduced intensity (no hills or speed training).

At two weeks, fitness tests showed symptoms were elicited after 3 km jog so the athlete started graduated programme of running every third day, increasing each run 500m from 2km starting point ensuring that he remained symptom-free.

After six weeks he was back to full intensity training (cycling and running) with no symptoms.

He still had poor balance and stability on the right leg as compared to the left but the deficit had significantly reduced. He was encouraged to continue his rehabilitation programme to rectify all predisposing factors in order to prevent a likely recurrence of injury.

Mark Alexander

Article published by the Sports Injury Bulletin

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