By Dawn Lewis
What do we know about the iliotibial band? It is a thick band of fibers that originates at the anterior superior iliac spine and the anterior aspect of the inferior lip of the iliac crest, and inserts on the lateral condyle of the tibia and Gerdy’s tubercle (which is slightly distal and anterior to the lateral condyle) on the tibia. The main job or action of the IT band is to stablilize the knee or tibiofemoral joint. It also stabilizes the iliofemoral joint and keeps both the knee and hip from dislocating.
This seems pretty straight forward. The IT band, as a thick band of connective tissue, is supposed to be taut. This allows it to provide stability to the knee joint. Two muscles attach directly to the IT band. They are gluteus maximus and tensor fasciae latae (TFL).
Recognized disorders of the IT band, such as iliotibial band friction syndrome or iliotibial band syndrome, arise from the fibers becoming overdeveloped or too tight and rubbing against the knee and hip bones during movement.
My question would be why do the fibers become overdeveloped or too tight? What happens when gluteus maximus and/or TFL become facilitated or hypertonic? Since the fibers of gluteus maximus and TFL blend into the IT band, excess tension in either of these muscles will cause excess tension in the IT band.
Okay, so what causes excess tension in gluteus maximus? Since gluteus maximus originates at the inferior posterior sacrum, the posterior coccyx, and the posterior iliac crest, a shift of these bones can cause additional tension in the gluteus maximus they shifted toward. These bones can shift in response to tension in the pelvic floor muscles, external oblique, internal oblique, latissimus dorsi, the erectors, lordosis, scoliosis, lumbar or sacral misalignments, or tension in the posterior hip muscles.
Gluteus maximus inserts on the IT band, but it also inserts on the gluteal tuberosity of the posterior femur. This means that the position of the femur can also create excess tension in gluteus maximus. The position of the femur is influenced by the balance of the muscles in the thigh and hip. For example, the tension of vastus lateralis and vastus medialis needs to remain balanced to keep the femur from shifting. If, for example, vastus lateralis is holding more tone than vastus medialis the femur will likely shift lateral and possibly into lateral rotation, creating more tension in gluteus maximus.
The excess tension in vastus lateralis, which inserts on the tibial tuberosity through the quadricep tendon and patellar ligament, also has the potential to pull the tibia into a position of lateral rotation. If the tibia, where the IT band inserts, is in lateral rotation, the posterior fibers of the IT band are likely to become tightened further. These are the same fibers that initiated from the gluteus maximus insertion, so this will create more excess tension in gluteus maximus.
Let’s look at two different possibilities of what would happen to TFL in our scenario. One possibility is that TFL will become inhibited or have less than normal tone. In this scenario the lateral rotation of the femur at the iliofemoral joint would be enhanced. One of TFL’s actions is medial rotation of the thigh at the hip. This counterbalances the lateral rotation of the thigh at the hip performed by gluteus maximus. So when TFL is inhibited, gluteus maximus becomes further facilitated or hypertonic, which creates more tension in the IT band.
The second possibility is that the tension in gluteus maximus has pulled the femur head proximal into the acetabulum and shortened the superior aspect of the iliofemoral joint. In this case, TFL may feel very shortened and tight. This does not mean that it is facilitated. The muscle may still be inhibited and unable to fire properly.
Now this is getting more complicated. Further complicating our understanding of the IT band is the knowledge that the gluteal aponeurosis adheres to and blends with the IT band. The gluteal aponeurosis originates from the posterior iliac crest and inserts on the IT band. It covers the most anterior fibers of gluteus medius. It also gives rise to the uppermost fibers of gluteus maximus. If we follow this line into the lower back and onto the posterior sacrum we see that gluteus maximus and the gluteal aponeurosis blend with the thoracolumbar fascia of the lower back and sacrum.
Instead of going higher up the body, let’s go back to the IT band. We now know that at the level of the greater trochanter, the IT band takes fibers in from gluteus maximus, TFL, and the gluteal aponeurosis. To add to this knowledge, it should be noted that the IT band actual begins as three distinct layers. The layers are the superficial, the intermediate, and the deep. These layers merge and insert on the lateral condyle of the tibia and Gerdy’s tubercle.
Although there is a solid case to be made for excess tension in the IT band stemming from a shift in the hip, sacrum, or coccyx bone, and just as much of a case to be made for excess tension in the IT band stemming from muscle imbalances in either the hip or the thigh, I am always drawn to the lower leg as the possible cause.
This would be because the anterior fibers of the IT band connect into the tibialis anterior muscle, which originates from the lateral condyle of the tibia, the proximal 2/3 of the tibial shaft, and the interosseus membrane. After crossing the front of the ankle and moving along the medial side of the foot, tibialis anterior inserts on the base of the first metatarsal.
For me, this means that the position of the foot at the ankle and the intricate workings of all the intrinsic muscles of the foot have quite a bit to do with tension in the IT band. Just this week I had a client come back in after a 90 minute massage session where I had talked him into letting me work on his feet and lower legs to alleviate his hip pain. He looked me straight in the eye and very seriously said, “you were right, that foot work really helped my hip pain.”
Part of me really wanted to explain that this was due to the oversupination of his right foot causing a lateral shift in the tibia and excess tension in the tibialis anterior muscle, which results in excess tension in the IT band, which happens to thicken at the greater trochanter – right where his pain generally is – due to a convergence of two muscles and an aponeurosis, but I just smiled and nodded.