I probably have IT Band Syndrome. Now what?

(originally published on Mungerruns)

A couple weeks back I discussed a possible injury to my knee. After investigating a little further and talking to some other runners, I'm fairly well convinced I have IT Band Friction Syndrome, or ITBFS.

But there's IT band, and there's IT band. One runner in our group, Marc Hirschfield, has been so gravely affected by IT band that he hasn't run since early January. Another, Jeremy Alsop, has been bothered by the condition for weeks, but that didn't stop him from running in a 50K ultrarunning event last weekend. I've had niggling tweaks, but not a lot of pain, and my running has hardly been affected at all. I'm setting PRs and running farther than ever. What's the difference?

It's probably just a matter of degree. According to this article, there are five grades of IT Band syndrome:

• Grade 1: Pain does not occur during normal activity, but generalized pain is felt about 1 to 3 hours after sportspecific training has ended. Tenderness usually resolves within 24 hours without intervention.
• Grade 2: Minimal pain is present towards the end of a training run; performance is not affected. Appropriate treatment may be necessary to prevent a Grade 3 injury.
• Grade 3: Pain is present at an earlier onset of training, and interferes with the speed and duration of a training session. Treatment and training modification are necessary to prevent a Grade 3 injury from progressing to a Grade 4 injury.
• Grade 4: Pain restricts training and is also noticeable during activities of daily living; the athlete can no longer continue sport-specific training. Low-impact training, such as swimming, running in a pool, and biking, can be implemented for cardiovascular fitness and aggressive musculoskeletal therapy can reduce the severity of the injury. The goal of therapy is to reduce inflammation and restore strength and flexibility of the hip and thigh musculature, allowing for the athlete to return to pain-free sport-specific training.
• Grade 5: Pain interferes with training as well as activities of daily living. Aggressive therapy is required and surgery may be necessary.

I'm probably somewhere around Grade 2. Jeremy might be more like a Grade 3, and Marc is at least a Grade 4. I'm a little skeptical of the article I linked above, though. While it gives a good description of the condition, to my mind it's not very scientific in its analysis of the possible treatments. If you surf around the web, you'll see dozens of different stories about sure-fire treatments, many of which are mentioned in this article. It's possible that all of them are doing some good. But what really works and what represents wasted effort? For that, we need serious clinical research. 

I found one review of the clinical research on ITBFS here. Ellis, Hing, and Reid assessed all the research they could find on the topic, but only four studies were well-controlled enough to merit review. Each study looked at different approaches to treating the injury, and even in these cases, the control wasn't ideal. For the most part researchers assumed that stretching and massage should be part of the treatment, and generally just studied additional remedies beyond the basics. Few checked to see if the stretching and massage were actually doing any good. For the most part, the studies all worked the same way -- treat for a week or so, then put the runners on a treadmill and see how much pain they feel. All the studies were quite small, with a few dozen participants at most.

Here's what Ellis's team found: Anti-inflammatory medication and pain medication is good, and probably helps. A cortisone shot definitely helps in the case of acute, rapid-onset ITBFS but the evidence is less clear for chronic ITBFS. Immobilizing the knee does not help. And one study found that deep massage probably doesn't add any benefits beyond what is obtained from stretching exercises and ultrasound.

But ITBFS is complex. Does an anti-inflammatory without stretching help? How well would you do if you just rested a couple weeks with no treatment at all?

Based on what I see here, I will probably try to do some strengthening exercises. There's a good list of them here. I'll also do some stretching, as instructed here. For now, I'm not going to invest in a foam roller, although many people swear by them—given the lack of evidence that massage helps much, it sounds like it might be a fruitlessly painful experience. But if you're interested, here's a video explaining how to do that. I will probably continue to wear a knee brace most of the time, primarily to keep my knee warm while running. Unless things don't improve or start to get worse, that's about it. Keep your fingers crossed!