Massage versus Foam Roller for the ITB
The Iliotibial Band (ITB) has a poor reputation in sports and sports medicine. A tight ITB is often associated with sports injuries and problems such as iliotibial band friction syndrome and anterior knee pain. The ITB is however connective tissue. It doesn’t contract, or relax, and you can’t directly strengthen or lengthen it. So why do people feel better after foam rolling or massage to the area? And should you indeed be foam rolling the ITB at all?
The ITB is often thought to be a singular discrete structure, running from the Iliac crest (side of the pelvis), TFL and gluteus maximus muscles, down to attach to the lateral condyle of the tibia bone (lateral side of the knee). The ITB is actually a thickening of the Fascia Lata; stocking-like connective tissue that surrounds the entire upper leg. The ITB is also anchored to the femur (thigh bone) via the intermuscular septum (tissue between the lateral quads and hamstrings). Dr Andy Franklin Miller described this anatomy in more detail in a recent Linkedin post.
Picture: Iliotibial band anatomy
I hope I didn’t lose too many people with the anatomy lesson, however I feel that it’s important to understand the ITB is a passive structure that is influenced by the many muscles around the region – the TFL and glut max muscles that attach to it proximally, and the quadriceps and hamstrings that can pull and tug on the fascia lata which in turn can create stress and tension on the ITB. Weakness and/or asymmetry in any or all of these muscles, particularly combined with repetition (running and cycling) can contribute to problems with the ITB.
Typically, sports people and health practitioners will say that the ITB is “tight” and needs to be “released”. Massage, foam rolling, and dry needling are the most common forms of treatment/management for a “tight ITB” and all these treatments in my experience can work to an extent. But it can be hit and miss.
The reason these treatments can work is not by loosening or releasing the ITB; remember the ITB is connective tissue that can’t really lengthen (0.2% max). The treatments work by reducing tone in the adjacent muscles that contribute to ITB tension – the quads, hamstrings, TFL and gluteals. Muscles are being released (a better term is relaxed), and the most important of all these is the TFL.
A cliché I like to use often is “weak muscles get tight”, so the primary issue is usually a strength deficit, sometimes biomechanical, sometimes overuse, sometimes a combination, rarely flexibility.
The last point I’d like to make is that generally, connective tissue doesn’t like to be compressed. Think of having your Achilles tendon pinched for a few minutes, or kneeling on a hard surface for a while (patellar tendon). Foam rolling is a compression activity, and whilst it may help release tone and tension in the muscles, it can and does cause irritation of the ITB. I’ve had plenty of patients complain that they feel worse, not better when they foam roller the lower part of their ITB – just above the knee. There’s also a bursa in the area, and bursae don’t like being compressed either.
For all the reasons mentioned, I’d encourage sports people and health practitioners to stop heavy compressive treatments of the ITB, rather focus on relaxing muscles - especially the TFL and gluteals. Foam rolling these muscles is tricky and usually painful, so in my opinion, massage therapy is the choice modality for the TFL and gluteals, and in turn the best manual treatment to combat problems of the ITB.
- Falvey, E.C., Clark, R.A., Franklyn‐Miller, A., Bryant, A.L., Briggs, C. and McCrory, P.R., 2010. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scandinavian journal of medicine & science in sports, 20(4), pp.580-587.