March 25, 2006 — Tangents
The iliotibial band is the longest tendon in the body. It connects the hip to the tibia (shin) and runs along the outside of the knee on the way. If you bend your knee slowly back, at a bend of about 30 degrees you can feel the IT band roll over a small bony projection on the outside of the femur beside the kneecap (called the lateral femoral epicondyle). A fluid-filled pillow cushions the band and normally this rolling motion is not noticed. However, certain conditions can cause an increase in friction which leads to a painful inflammation of the tendon. This is known as iliotibial band syndrome.
I first experienced ITBS when running about four years ago. The run itself was normal and pain free, but when walking a few hours afterwards I suddenly began to feel pain at the outside of my right knee. This was manageable on level ground where I could walk stiff-legged but going up stairs was difficult, or at least strange looking. For a while I used mostly my left leg to climb stairs and hills, but soon the left leg developed the same symptoms as the right and I was forced to pull most of my weight up stairs by the handrails and walking anywhere became a chore. After about a week of rest and icing both knees the symptoms were gone, but even a small amount of running (a minute or two) brought them back. This state of affairs has continued until recently, when I have seriously started addressing the issue in relation to bicycling.
I am not a doctor. What I am writing about here are the things I've learned from my experiments and personal experience and from talking to physical therapists, podiatrists, trainers, and athletes who have had IT band problems. If you have ITBS I hope this article helps but don't believe that I am any kind of authority on the subject. Please, do your own research and experiments and become an expert on your particular body. It will be worth the work.
Firstly, IT band syndrome is not a knee problem. It is the inflammation of a tendon that happens to occur near the knee (or, in some people, the hip). Therefore, be careful about accepting general advice about knees. Often what's best for the knee is bad for the IT band, such as a bicycle seat height which brings the legs to near-full extension at the bottom of the pedaling stroke (more on this later). Along these lines, also beware generic cycling advice about pedaling style and posture. If you have ITBS you are not the generic rider, but few bike fitters will understand this if they have not had ITBS themselves.
I began my own study of the problem by standing in front of a mirror. I recommended doing this yourself so you can get a feel for what's causing the problem. The first thing I noticed is that I am bowlegged. If you are bowlegged you are a prime candidate for ITBS because the lateral femoral epicondyle (that knob at the outside bottom outside of the femur) is pushed out towards the iliotibial band, and the band itself is stretched a bit more tightly than usual. Bowleggedness, as far as I know, is not correctable post-babyhood. You have to change how you use the bowlegs.
The second observation: the path of my knees when walking changed noticeably when I rolled my weight over different parts of my feet. Watching in the mirror while rolling a foot, in a normal walking motion, on the outside (weight on the small toe) and then on the inside (weight on the big toe) I saw that the knee jutted outwards briefly when rolling over the ball or outside and went straight forward when rolling over the inside. I also tried approximating a bicycle pedaling motion, "pushing" with the big toe, then with the ball of the foot, and observed a similar change in knee movement. Clearly, any motion that causes a jutting outwards of the knee is not desirable for the same reason bowlegs are undesirable.
Generally, ITBS can be caused by anything (due to body shape or technique) which pushes the femur outwards or tightens the IT band. Examples include:
Unlike some injuries you cannot "ride through" IT band problems. Since ITBS is an irritation due to friction continuing activity will only make it worse. You must rest, treat the problem, and then build back up to your old routine. The good news is that if your situation is not too severe a solution may allow you to go back to your usual routine almost immediately. However, experimentation will require some patience. Take the opportunity to learn about your biomechanics and improve your form. I experienced a sudden increase in strength from a homemade orthotic wedge and now understand better how to pedal using different muscles to give the quads a rest.
The following suggestions are listed in approximately increasing order of severity and cost. I have not tried the last three and am not suggesting that any of them will work for you. I describe them here only to tell you what I've learned and what my ideas are. You still have to do your own research and exploration. When trying anything, please be sure to stay aware of how your whole body feels, not just the problematic area. Beware of techniques which eliminate IT band pain only to cause a new injury somewhere else. Also, these suggestions are aimed at solving the problem, not easing the symptoms. If you need immediate relief try icing the point of inflammation (ultrasound, if available, may help too) and stretching the IT band. And most importantly: rest.
Traditional bicycle fitting systems usually place the seat at a height where the legs approach full extension at the bottom of the pedaling stroke. Try lowering it to reduce tightening of the IT band. You will probably notice a decrease in power but this may lessen as your muscles become accustomed to the new setup. (And some of the subsequent suggestions should help you gain power.) I consider seat-lowering an essential first step if your seat is at the "normal" height.
This has a similar effect to lowering the seat but may help to compensate for lost power. Some bike shops will tell you to place the seat so as to align the front of your kneecap vertically with the pedal spindle, but this is not necessarily good advice for you. Experiment and see what feels right for your uniquely proportioned body.
Stretching can help in the short term to lessen the symptoms of ITBS, but also in the long term if your IT band retains the extra bit of length. I have not benefitted personally from stretching but it does work for many people. One stretch you can do is this: stand with your right hand resting on a desk, chair, or other prop placed about two feet to your right (this description applies to stretching the right IT band, reverse for left). Take a small step forward with your left foot and then extend your right leg straight out to the left side (behind the left leg) using your right hand on the prop to maintain balance. The outer side or perhaps even the top of your right foot will be in contact with the ground. Extend the right leg out as far as it will comfortably go and lower your weight until you feel a gentle stretch in the band between the hip and knee. The position is something like a forward lunge except that you swing the back leg out 90 degrees to the side behind the front leg.
Use what you might have noticed when watching your legs in the mirror: that the knee stays straight (doesn't jut out to the side) if you roll your foot in a certain way. For me that certain way is over the big toe. I've actually taken my toe clips off the pedals since they are of no help when pedaling in this fashion. Note that this pedaling technique also has a similar effect to moving the seat forward except that it's more like moving the bottom bracket back because you don't change the seat-to-handlebar distance. It also has an effect somewhat similar to lowering the seat, but the significant change is the change in path of the knee.
When pedaling, you should be able to find a cadence which is both fast enough to sustain momentum and slow enough that you don't wear out your knees too quickly. Maintain this rate by changing gears on hills and allowing your riding speed to vary. This is a good practice for most cyclists, and should minimize IT band friction.
Another idea is to try to pull the knee inwards (away from the IT band) by strengthening the infrequently used inner thigh muscles (Vastus Medialis). You can do this in a gym with with a low pulley machine or at home by sitting on the floor, legs straight in front of you, and doing leg raises (one leg at a time) with the foot being raised turned outwards. Go very slowly and use ankle weights if you need some resistance, but I'd recommend a long light workout over a short heavy one. I have been doing this for some time but can't comment on its effectiveness as I've been trying many other things concurrently and the strengthening process is gradual.
I highly recommend trying this if you have pronated feet: using rubber, make wedges which fit into your shoes and raise the outer front portion of your foot, correcting pronation and causing you to ride somewhat knock-kneed (but not too much; experiment with the height of the wedge). For a while I tried riding knock-kneed without the wedges, but actually putting them in resulted in a surprising increase in power (more than 1 mph average speed) not to mention reduced IT band pain. Professionally-made orthotics may also be of help, especially if you have high or low arches. (Note: Some biking shoes, like Specialized's Body Geometry series, are shaped to correct for knock-kneed legs and will put your feet in a worse position than regular sneakers. Beware the shape of your shoes!)
To reduce the tightening of muscles near the knee you can try pedaling with muscles higher up and in the back of the leg: the Gluteus Maximus and, to some extent, the hamstrings. To get my legs to do this I relax my quadriceps and imagine the muscles on the backs of the legs pulling the pedals down and back rather than the quadriceps pushing forward and down. It feels strange at first, especially because you may be sitting on or near the muscles you're using to pedal (you might need to sit a little differently on the saddle) but I believe this was one of the most effective changes I made. Beyond helping with IT band pain, being able to pedal with a different set of muscles allows me to give the quadriceps a rest, or use the quadriceps to give the glutes a rest. Seat adjustment and Biopace chainrings may ease the process of learning this pedaling technique.
Several companies sell flexible straps you can put around your quadriceps two or three inches above the knees to prevent the offending tendon from snapping back and forth across the bone. They cost under $20 per pair and have provided me with some relief in combination with other solutions listed here. It is also possible to make your own. Just be sure the material is flexible enough to apply pressure without cutting off circulation and that the inner surface is tacky enough to stay in place.
In the late 1980s Shimano started making non-circular front chainrings called Biopace. These were standard equipment on many bikes for several years but production has long since ceased. The Biopace design is the opposite of the elliptical chainrings I've seen on the market recently in that it reduces the size of the gear during the power stroke and increases the gear in the dead zone. This might not make sense a priori, but after riding a bike with Biopace chainrings for 13 years which caused no IT band pain I would venture to say that there's something to it. Specifically, with Biopace chainrings I experience an increased ability to sustain pedal momentum. The feeling is that of being able to shift my weight and just let my legs drop, throwing the pedals through the dead zone. There is almost no pushing at all, and certainly less load on the leg muscles near the point of greatest extension. When pedaling at high speed I am also less likely to start rocking in the saddle (the result, I think, of the pedals slowing at the top and bottom of the stroke). Obtaining Biopace chainrings these days involves some searching. Most likely you will have to get them used. Make sure they are not too worn and check out all the usual factors involved in crank compatibility (bottom bracket type, chain width, size of rear cassette, etc).
If your legs are of unequal length you might try using unequal length cranks. As my legs are very close in length I have never tried this, nor have I heard of it being tried. As with any of these suggestions, maintain awareness of how your body feels and take seriously any unusual sensations. Also keep in mind that not all cranks have the same profile (i.e., some will stick out farther from the centerline of the bike) and you will probably want a pair that match.
Trigger points are spots in a muscle which, when pressure is applied, refer pain to other areas in the body. Trigger points are usually caused by injuries and can persist indefinitely if not treated. It is possible that what seems like IT band pain is instead a trigger point condition in the tensor fasciae latae (the symptoms are quite similar). It is also possible that an IT band problem has caused trigger point conditions. In any case, trigger point therapy (which uses massage techniques) may be worth investigating.
I have not had cortisone shots but have been told they can provide relief from pain for several weeks by loosening up the IT band. Cortisone may also provide more permanent assistance by dissolving some of the scar tissue which builds up each time the tendon is inflamed. However, some people have negative reactions to cortisone, and it may weaken the tendon somewhat. Be sure to do thorough research and try to avoid using cortisone as a quick fix, squandering the opportunity to learn about your legs.
Prolotherapy is a practice (which dates back to the ancient Greeks) involving the intentional creation of an inflammation near an area of moderate pain so that the body will take it more seriously and heal the wound. Treatment generally involves a series of injections (usually of sugar water) which take place over a number of weeks. I have no experience with prolotherapy and am somewhat skeptical of its ability to solve IT band problems. Practitioners claim that it strengthens ligaments and tendons. While this makes sense I'm not sure how strengthening the IT band will eliminate friction which is a result of body shape or cycling technique. Nevertheless, if you've tried everything else you might want to investigate prolotherapy.