Does stretching the iliotibal band (ITB) conjure up scenes of torture? For many clients it seems to be a rite of passage, if the treatment has not taken a client’s breath away it can lead to doubts of how good a therapist is or how successful the treatment was. This article will challenge the old school of thought, ‘deeper is better’ when it comes to treating the ITBS, and that giving it a bit of elbow will sort it out. It won’t! I am proposing a different intention, how to deliver the best treatment with minimal discomfort particularly given the sensitivity of the ITB. I will be demonstrating how transverse soft tissue release can offer an effective form of treatment for iliotibial band syndrome while dispelling the ‘deep is better’ myth. The article includes a detailed video showing the manual techniques described along with a certificated continuing education assessment and some practical client advice.

Illiotibial band (ITB) syndrome is a common condition often associated with runners, cyclists and weight lifters (those who perform a lot of squats). The tension felt in the ITB is often mistaken for the problem rather than the symptom. All too often I hear from the lips of my athletes “my ITB needs to be stripped” – an aggressive word that conjures up a medieval approach to resolving what is not so much a muscle but a connective band. The word ‘connective’ is key and plays a vital role in our decision making process when determining the best approach for treatment. In this case study I have highlighted how transverse soft tissue release (STR) can be an effective tool in the rehabilitation of ITB syndrome.

Case study

History and presentation

A relatively new runner had just completed his first marathon, he has no history of any serious injuries that prevent him from running or training, but recently he suffered a sharp pain around the outside of his left knee leaving him barely able to walk after a 5 mile run. He found it hard to bend his leg when walking and continues to find it difficult to go down hills or flights of stairs. The problem started after returning to training 1 week after the marathon. He had an X-ray and an MRI scan, and although neither showed any sign of significant pathologies, the MRI did show a slight thickening of the tissue on the lateral side of the knee. At this point, despite the inconclusive medical investigations, the current severity of the injury continued to interfere with his everyday life and he had not been able to train for 3 weeks. He had been to see a physiotherapist and acupuncturist, which helped and the exercises and stretches given to him had also helped, but he continued to be limited in his ability to run because of the pain. He had then been recommended to see a sports massage therapist.

Despite having stated in his original interview that he did not have a history of any previous injuries upon further questioning the client admitted to having an earlier episode of an ITB problem the previous year. This was resolved by a period of rest and making adjustments to his stretching routine.

Findings from palpation and ROM testing showed a tendency to overpronate and he had a mild case of bunions bilaterally (more severe on the left). There were rough calluses on the medial edges of the hallucis – calluses often indicate that there is excessive rubbing usually as a result of poor mechanics. Both ankles were stiff with a restricted glide in dorsiflexion and the Achilles tendons were tight bilaterally. Further up to the knee, the patella moved freely medially but was very restricted laterally by the ITB and vastus lateralis; poor muscle tone was felt on the medial and central quadriceps and further exploration revealed a lack of gluteus medius engagement and weak hip strength.

Iliotibial band syndrome

These findings point toward ITB syndrome, a suggestion made to him by his consultant. This condition is common in both cyclists and runners; for the former it can be the result of having the seat too high forcing the leg into full extension while pedalling, and for the latter it can be caused by the knee turning inward as a result of poor foot mechanics, uneven surfaces or worn-out shoes. All of these conditions place repeated stress on the outside of the knee where the ITB inserts, often causing inflammation. One of the goals of treatment is to reduce the inflammation, a conventional approach recommends the use of anti-inflammatories and rest.

What is the best treatment for ITB syndrome?

Pain is often thought to be indicative of a short ITB yet despite studies finding that the ITB is often long in these circumstances, therapists often try to stretch the ITB to loosen it off. This activity is comparable to trying to stretch a tough piece of leather and, inevitably, the therapists make virtually no impression. Studies confirm that despite the use of stretching techniques, equipment or manual therapy, the length of the ITB was found to remain the same. Interestingly enough another study showed that if you stretch the hamstrings, 240% of the resulting strain is on the iliotibial tract and 145% is on the ipsilateral lumbar fascia (1).

My questions for you are, after considering the information from above, “Is the restricted movement in the ankles, the overpronation, the lack of muscle strength in gluteus medius?”, and “What would happen if we released the ITB – where is his stability going to come from?” Therefore, after considering this information do you want to stretch or soften it? What role has the ITB been forced to take on in this situation? A ‘tight’ ITB can be telling you that it is working hard to stabilise the action between the hip and knee (TWEET THIS). A study conducted by the University of Calgary’s Running Injury Clinic found that the problem was due to a lack of strength in the hips, rather than the ITB tension. The runners that they worked with in their study started with 30% less hip strength than an average healthy runner and after correcting the deficiency using strength exercises they returned to running pain-free. The study has its weaknesses in reporting its results but it does highlight that there is more to consider than just resolving the condition by stretching.

The intention of my sports massage sessions is to lessen the stress being placed on the knee, encourage proprioception to the weak muscles and encourage hydration and softness to the areas that are tight. This does not involve ‘stripping’ the ITB, but lessening the tension using techniques that encourage a softening rather than making it slack (TWEET THIS). It is important to maintain the stability of the knee joint while trying to bring an equality of function to the surrounding muscles and tissue. Typically, therapists find that the deep work they do only temporarily resolves the problem with the pain returning all too soon. The next step is to introduce strengthening exercises. Muscle Energy Techniques can prepare the muscles by initiating proprioception responses within, often it is a bit like turning the light switch on, triggering a neuromuscular response within the tissue. Further and more complex strength exercises are best taken over by those in the profession who specialise in this type of work such as a strength and conditioning coach, physiotherapist and/or a personal trainer. Some of the key exercises might include the use of resistance bands with the main focus in strengthening the hip abductors, extensors and gluteus medius.

Sports massage can be the magic pill that resolves many issues, but with ITB syndrome, although we can play a significant role, sports massage is not a complete solution . Remember, the intention of your session should be to leave your client better than when they came in by decreasing tension, not necessarily just in the ITB but also in joints or soft tissue that restrict functional movement . This is one of my primary goals with any session.

With that in mind, one of my favourite techniques is transverse soft tissue release (STR). The main intention of transverse STR is to affect fascia, a major component of connective tissue. As we know, manual methods stimulate tissue repair and remodelling in both hard and soft tissue. Transverse STR uses this principle by applying a mechanical load, compression, and a shearing transverse movement that specifically targets the Ruffini endings and interstitial mechanoreceptors. The mechanocoupling will agitate cells resulting in releasing chemical signals within and amongst the cells creating cell-to-cell communication from one location to distant areas. What this means for us as therapists is that our work is not just about the area we are working on but affects the body globally. For example, if you are working on the hips you will have an effect on tissue further afield.

Massage assists the healing process through mechanical loading which stimulates the effector cells to respond by increasing protein synthesis at a cellular level promoting tissue repair and remodelling. From a neurophysiological viewpoint, soft tissue and manipulative approaches appear to evoke a nerve response in the fascia, resetting patterns or stimulating new ones.

Transverse STR can be both a direct and indirect fascial approach which helps to loosen the area and rehydrate the tissue, encouraging oxygen to return stimulating the healing process. ‘Hypoxia can amplify the early inflammatory response, thereby prolonging injury by increasing the levels of oxygen radicals’ (2,3).

The latest research is helping us to understand the nature of fascia and also the type of techniques that are effective in releasing restrictions. According to Schleip et al. (4):

“Fascia is densely packed with mechanoreceptors that we know ARE responsive to manual therapy. In particular the Ruffini and Interstitial Receptors.”

“These mechanoreceptors also influence local fluid dynamics and vasodilation.”

What is lacking? Nowhere has it been mentioned that heavy-handed stripping is needed in order to evoke a change. The alternative choices are a lot easier to apply and don’t require you to use the heel of your hand to drill into the thigh in a most painful manner.

Transverse soft tissue release

Transverse STR is similar to other forms of STR, wherein a lock is achieved, but where it differs is in the direction of the lock. Rather than putting pressure through the muscle that changes its length (its origin), the lock creates a shape change, taking up the slack across the fibres so that when you perform the movement transversely wherein you can achieve a stretch. This is ideal when you have big muscles, like the hamstrings and quadriceps, as you can use both hands to get a good depth without stressing your hands or thumbs.

Other advantages of using transverse STR are listed below:
 1. More control of muscle when there is a greater range of movement 2. Useful when the depth of muscle is shallow 3. Can help in preventing overstretching or lengthening of the tissue longitudinally but conversely can help to release tension or separate adhesions 4. Can be applied when there is no solid or supportive structure beneath the hands 5. Useful when the muscle fibres are multi-pennate or circular.

The application of transverse STR

In the case of ITB syndrome it can be used to target a tight area or applying a broader method to encourage softness and more circulation to the area. the idea is to lift the tissue to create a ‘C’ curve into the targeted muscles, in this case the hamstrings. Lock into position with the heel of your hand, pushing the tissue away from you (taking up the slack) and then pull the leg towards you with the other hand until you feel a stretch. In this situation the action is passive but you can perform the same technique with a straight leg asking your client to rotate towards you as you push away.

When using this on vastus lateralis and ITB, stand on the opposite side of the couch, extend your arms and place both hands, one on top of the other, across to the outside of the opposite leg. Use a minimal amount of tension in your bottom hand, just enough to hold and engage the tissue, it is the job of the top hand to apply your depth and strength. This allows the bottom hand to have a softer yet more powerful contact with the tissue. If your base hand stiffens too much it will feel pokey and the muscles will react by tensing up. You just want enough of a connection that when you create your lock the tissue does not slip underneath your hand. Next take up the slack by pulling and creating a ‘C’ shape with the tissue. Then ask your client to externally rotate their leg, moving slowly until you or they feel a stretch. If you have taken up the right amount of slack and your lock is the right depth, your clients’ leg will only be able to move slightly (and I mean slightly). Repeat this in a rhythmical fashion until you have reached the desired change in the tissue. It is important to mention at this stage not to over treat. Ensure that any changes you do make allow the corresponding muscles to cope with their newfound freedom. It is better to perform transverse STR in smaller doses so the body is capable of making the appropriate adaptations (Video 1).

Transverse STR can also be used to target a more refined and delicate area such as working around the knee. As there is very little muscle mass in which you can get a traditional lock, the transverse method can allow you to approach the lock more superficially.

Some of the tricks that get you the best out of this technique is to slowly and sensitively apply a specific lock that is both stable and subtle. Keep it simple, really simple.

ITB client advice and homecare

What sort of advice would you give your client? Some examples might include:

1. Running should only take place if there is no pain.
   Decrease the mileage if pain is felt or take a rest period of a few days (or more), do not push through it otherwise you will do more damage and slow down the recovery process.
2. Warm up.
   Walk a quarter mile before you start to increase your pace, so avoid leaving the house at a full run – you will need to gradually increase your speed before you engage into a full run.
3. Make sure your shoes are appropriate for you.
   Shoes are made to fit different types of feet and mechanical patterns, make sure you have the right trainers for you, seek advice from a professional shop that can assess you and kit you out appropriately.
4. Train according to the type of surface you are competing.
   However, initially start on flat surfaces that offer a more predictable route. If you are running on a track, change direction regularly.
5. Increase gradually.
   Use the FITT (frequency, intensity, time and type) principle and only change one of these at a time. For instance, increase frequency gradually, if this does not cause a return of your symptoms then move onto increasing one of the other variables.
6. Fluid intake/nutrition.
   Make sure you are taking on an appropriate amount of hydration. Increase your protein intake especially while you are going through the rehabilitation process.
7. Most importantly, have regular massage or self-massage.
   This will help to mobilise and maintain optimum performance. It is all about prevention and getting the most out of your performance – having regular massage will help with this and keep your tissue healthy and fit.

This is a general list of advice but each client needs to have a personalised plan, so whatever intrinsic or extrinsic factors have led to their condition will need to be included as homecare.

To recap, look at the contributing factors both externally and internally and address these as part of your homecare, incorporate other modalities for a more sustained change (ie. strength work), use a variety of techniques within your treatment, consider the overall global functional movement patterns when making decisions about where to treat. Remember ITB syndrome is usually the symptom rather than the problem.

Further resources

1. Fritz S. Sports & exercise massage: comprehensive care for athletics, fitness, & rehabilitation, 2nd ed. Mosby 2013. ISBN 978-0323083829. View on Amazon
2. Johnson J. Soft tissue release: hands-on guides for therapists. Human Kinetics 2009. ISBN 9780736077125. View on Amazon
3. Avison J. Yoga: fascia, anatomy and movement. Handspring Publishsing 2015. ISBN 978-1909141018. View on Amazon
4. Journal website: Journal of Bodywork and Movement Therapies

Key points

1. Transverse soft tissue release (STR) can be both a direct and indirect fascial technique which helps to loosen the area and rehydrate the tissue, encouraging oxygen to return stimulating the healing process (2,3).
2. Transverse STR can also be used to target a more refined and delicate area such as working around the knee and ankle to assist in changing joint function.
3. Transverse STR is an effective method that allows you to treat a specific area instead of the full length of the ITB (TWEET THIS).
4. Transverse STR is particularly suitable for challenging locations where accessibility is restricted due to their location and range of movement (TWEET THIS).
5. The transverse STR method maintains optimum control, maximum effectiveness with minimal discomfort (TWEET THIS).
6. Keep asking yourself when does loosening up become too much, what is the real intention of this treatment?
7. This article demonstrates how transverse STR treatment can give ease to the ITB without working directly on it (TWEET THIS).
8. The transverse STR technique on the ITB allows you to work with ease and minimises your effort (TWEET THIS).
9. Success in any manual therapy technique equates with working at a depth the tissue can respond favourably to (TWEET THIS).

Discussions

1. What is the real intention of loosening the ITB?
2. Are we really changing the length of the ITB or is it promoting an already established length?
3. What effect does the concept of biotensegrity have on treatment?
4. What influence does a sport have in the rehabilitation of a tight ITB?
5. Are we offering a permanent solution or is this a bandaid treatment?
6. What are the physiological changes that happen to the fascia, muscles and tendons? What does the research tell us.

Continuing education quiz

This article also has a certificated eLearning assessment that can be found in the Media Contents box, or under the eLearning Assessment area in your Account area, on the Co-Kinetic website. The eLearning assessment(s) can be completed on all platforms including mobiles when access through the Co-Kinetic site however they are NOT accessible through the sportEX mobile app as you have to be logged into the actual website for the results to be recorded and the certificate to be generated.

Quotations/important points

“Transverse soft tissue release (STR) can be an effective tool in the rehabilitation of ITB syndrome”

“The intention of massage techniques for ITB syndrome are to lessen the ITB tension by encouraging a softening rather than making it slack”

“Massage softens the ITB, but full rehabilitation then requires muscle strengthening exercises for the hip abductors, extensors and gluteus medius”

References

1. Franklyn-Miller A, Falvey E, et al. The strain patterns of the deep fascia of the lower limb. In: Huijing P, Hollander P, et al. (eds.) Fascia research ii: basic science and implications for conventional and complementary health care. Elsevier, 2009. ISBN 978-3437550225. View on Amazon
2. Mathieu D, Linke JC, Wattel F. Non-healing wounds. In: Matthieu D (ed.) Handbook on hyperbaric medicine. Springer 2006. ISBN 978-1402043765. View on Amazon
3. Woo K, Ayello EA, Sibbald RG. The edge effect: current therapeutic options to advance the wound edge. Advances in Skin & Wound Care 2007;20(2):99–117
4. Schleip R, Klingler W, Lehmann-Horn F. Active fascial contractility: Fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics. Medical Hypotheses 2005;65(2):273–277.