In recent years, the iliotibial band, a seemingly unremarkable anatomical structure, has been the subject of sometimes-intense debate by academics, athletes, bloggers, hands-on practitioners, researchers, and physical trainers. Can it be stretched? Should it be rolled? The ongoing debates have ensued from a more complete understanding of this structure’s anatomy and function (which I will briefly review here), and from updated views on how fascia does and doesn’t change (a topic that has been discussed in detail in this column, as well as elsewhere).
Conventionally, the iliotibial band (or ITB; also known as the iliotibial tract, IT band, or Maissiat’s band) has been depicted as a fibrous strap of connective tissue along the lateral side of the thigh, running from the iliac crest to the tibia (Image 1). What isn’t obvious in conventional muscle-based illustrations is that rather than being a discreet band, the ITB is simply a thickening in the fascia lata, the fascial wrapping that encases the entire leg (Image 2). And the ITB isn’t just on the surface of the leg; it dives deeply into the thigh as an intermuscular septum, where it attaches along its entire length to the femur (Image 3).1
The ITB can be involved in numerous client complaints, such as those listed in “Indications” on page 110. Much of the research related to the ITB centers on iliotibial band syndrome (ITBS), which is the most common lateral knee injury in runners, often worse when flexing the knee or running downhill. Conventionally thought of as an overuse injury, and experienced by an estimated 5–14 percent of runners, the exact cause of ITBS is not well understood and there is little agreement on how to treat or manage it.2
Controversy
While there are diverse views about the ITB’s precise role in all the conditions we list here as indications, some of the more strident controversies have been about ITB self-care via foam rolling, or working the ITB in hands-on manual therapy. Articles and blog posts with titles such as “Don’t Stretch Your IT Band!” and “The Mechanical Case Against Foam Rolling Your IT Band. It Can Not Lengthen and it is NOT Tight,” cite research showing that the ITB’s length probably changes very little (perhaps 0.5 percent) as a result of stretching (and make the point that simple compression, such as that from a roller or elbow, would provide very little stretching force anyway).3 This is in line with research showing that the forces needed to produce change in high-density fascia (such as the ITB) are probably much too strong to be accomplished by manual manipulation.4
However, others have countered with the observation that many people’s function and symptoms seem to improve as a result of ITB work.5 In our Advanced Myofascial Techniques trainings, this has been our faculty’s experience as well—we see many benefits to including the ITB in our protocols, and work it in both our hip and knee sequences.
It is very likely, however, that the improvements seen are not the result of any permanent lengthening of the ITB. In fact, a more up-to-date view of fascial properties emphasizes the sensitivity (mechanoreception, nociception, proprioception, etc.) of fascia over its mechanical qualities. Dense fascia like the ITB is richly innervated with many kinds of mechanoreceptors, such as Golgi tendon organs (sensitive to strong stretch) and Ruffini corpuscles (which sense both stretch and tangential, or shearing, forces). Both of these mechanoreceptors lower tissue tone when stretched with slow, deep pressure.6
As anyone who has used a foam roller can confirm, the ITB is sensitive. (And so are the tissues around the ITB, such as the highly innervated loose connective tissue and fat between the ITB and the tibial condyle, which is thought to be a major source of ITBS pain.7) The function of sensitive tissues is to sense, and in the case of the ITB, it’s likely this sensing helps us coordinate and stabilize our standing, walking, and running. In other words, we use our ITBs to perceive the forces passing around our hips and knees. The sense-organ capacity of the laterally positioned ITB makes it analogous to the lateral-line sense-organ of fish, which use theirs to sense the movement and forces around them (Image 4). So rather than thinking about lengthening the ITB with our work, it may be helpful to imagine that our work sensitizes and gently awakens the sensory and coordinative capacity of our own highly sentient lateral line.
Iliotibial Tract Technique
With your client comfortably side-lying, gently use the knuckles of your soft fists to engage your client’s skin and superficial fascia (Image 5, page 110). The bony prominences of the knuckles have the right balance of slickness and hardness that will allow you to modulate the amount of pressure and friction you use, so you can precisely tune the pressure and speed of your technique to your client’s comfort level.
With slow, patient, and gentle touch, apply friction to the skin and superficial fascia of the side of the leg. Begin at the hip, and as the tissue softens, its viscoelastic change will allow you to glide distally to the knee. Work layer by layer, a little deeper each time, making sure your pressure has the right balance of evoking sensation (which is the point of the technique), while not being so intense or painful that your client begins to tighten, guard, or resist. After a few slow passes, you’ll be able to feel past the now-mobile surface layers to the deeper layer of the fascia lata and ITB. Remember that this deeper, denser ITB layer is the top of a Y-shaped arrangement that goes all the way to the femur (Image 3).
Variations include active knee or hip movement; using a gentle forearm instead of a soft fist; or Advanced-Trainings.com instructor Larry Kola’s “Frozen Hose” variation of grasping, lifting, and gently shearing the iliotibial tract anteriorly and posteriorly. Whichever approach you use, take your time, working all around the lateral leg, from the hip all the way past the knee, keeping in mind that you are stimulating and refining the sensitivity of one our body’s many important sensory structures.
Key Points: Iliotibial Tract Technique
Indications
• Restricted hip adduction
• Hip pain in side-lying positions (sometimes related to greater trochanter bursa irritation)
• Local pain after direct trauma and injury to the lateral leg
• Knee injuries (the ITB can be damaged along with the lateral collateral ligaments and other structures of the knee)
• Knee strain and misalignment, particularly valgus (knock-knee) patterns (the iliotibial tract is sometimes cut by surgeons as a treatment for genu valgum)8
• Iliotibial band syndrome (ITBS)
Purpose
• Refine proprioceptive and sensory function of the fascia lata, ITB, and lateral leg
• Increase tissue elasticity and differentiation
Instructions
(Described in the text)
Movements
• Active knee or hip flexion
Homework
• Relaxing onto a foam roller under the ITB, with attention to sensation, breath, and relaxation
• One-legged balance activities, with awareness of ITB sensation and function
For More Learning
• “Pelvis, Hip & Sacrum, Parts I & II” and “Knee Issues, Part I” in the Advanced Myofascial Techniques series of workshops and video courses
Notes
1. John Fairclough et al., “The Functional Anatomy of the Iliotibial Band During Flexion and Extension of the Knee: Implications for Understanding Iliotibial Band Syndrome,” Journal of Anatomy 208, no. 3 (March 2006): 309–16.
2. M. P. van der Worp et al., “Iliotibial Band Syndrome in Runners: A Systematic Review,” Sports Medicine 42, no. 11 (November 1, 2012): 969–92; J. Shamus and E. Shamus, “The Management of Iliotibial Band Syndrome with a Multifaceted Approach: A Double Case Report,” International Journal of Sports Physical Therapy 10, no. 3 (June 2015): 378–90.
3. Paul Ingraham, PainScience.com, “Don’t Stretch Your IT Band!,” Accessed March 2016, www.painscience.com/articles/iliotibial-band-syndrome-stretch.php; Greg Lehman, “The Mechanical Case Against Foam Rolling Your IT Band. It Can Not Lengthen and It is NOT Tight,” accessed March 2016, www.greglehman.ca/2012/03/17/stop-foam-rolling-your-it-band-it-can-not-lengthen-and-it-is-not-tight/; E. C. Falvey et al., “Iliotibial Band Syndrome: An Examination of the Evidence Behind a Number of Treatment Options,” Scandinavian Journal of Medicine & Science in Sports 20, no. 4 (August 2010): 580–7.
4. H. Chaudhry et al., “Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy,” Journal of the American Osteopathic Association 108, no. 8 (August 2008): 379–90.
5. Carl Valle, EliteTrack.com, “Foam Rolling—Evidence Based Results?” accessed March 2016, www.elitetrack.com/blogs/details/6897/.
6. Robert Schleip, “Fascial Plasticity—A New Neurobiological Explanation,” Journal of Bodywork and Movement Therapies 7, no. 1 (January 2003): 11–19; L. Yahia et al., “Sensory Innervation of Human Thoracolumbar Fascia,” Acta Orthopaedica Scandinavica 63, no. 2 (April 1992): 195–97.
7. John Fairclough et al., “Is Iliotibial Band Syndrome Really a Friction Syndrome?,” Journal of Science & Medicine in Sport 10, no. 2 (April 2007): 74–6; discussion 77–8.
8. Frankie M. Griffin, Giles R. Scuderi, and John N. Insall, “Lateral Release for Fixed-Valgus Deformity,” in Knee Arthroplasty Handbook, eds. Giles R. Scuderi and Alfred J. Tria, Jr. (New York, New York: Springer, 2006): 41–56.
Til Luchau is a Certified Advanced Rolfer, the author of Advanced Myofascial Techniques (Handspring Publishing, 2016) and a member of the Advanced-Trainings.com faculty, which offers distance learning and in-person seminars throughout North America and abroad. Contact him via info@advanced-trainings.com and Advanced-Trainings.com’s Facebook page.