Spring marathon season is quickly approaching here in the northern hemisphere and as such I’ll be bracing myself for the influx of keen runners presenting with the characteristic lateral knee pain of ITB Syndrome, as their weekly mileage and long run duration increases.
Over the years my approach to assessing and rehabilitating runners suffering from ITBS has evolved significantly. The most notable changes in approach coming as a result of developing an improved understanding of the biomechanical factors affecting the injury.
Runner’s Knee Rehab Resources >>
Free Resources [PDF]
Cross-Over Gait & ITBS
While it’s vitally important to understand the biomechanics of both stance and swing phase of running gait, I feel a there’s often a lack of appreciation for how one affects the other. How the biomechanics of swing phase directly help to dictate those of the subsequent same-sided stance phase.
In his excellent recent article, Jeff Moreno DPT reminds us of the cyclical motion of running gait, and how swing phase just prior to initial contact, and proximal control of the contralateral stance phase, is just as important as the loading phase itself.
The image above demonstrates a common trait of many runners: increased hip adduction during late swing phase leading to the beginnings of the typical ‘cross-over’ gait pattern. Running on a tight-rope, if you will…
As was the case with this runner, this pattern often comes hand-in-hand with a contralateral pelvic drop in stance phase, and poor neuromuscular control of the limb in early to mid swing phase. See the slow-motion video below to watch her in action.
Consider the basic ITB anatomy for a moment… As our in-house physiotherapist Brad Neal mentioned in his article about the biomechanical causes of ITB Syndrome:
The tension within the Iliotibial Band will ONLY increase when the origin and/or insertion are moved further apart…
Brad Neal, Running Physiotherapist
Combining the landing foot position across the midline of the body, with a contralateral pelvic drop, we’re doing exactly what Brad describes above. We move the origins and insertion of the ITB away from one another, mechanically increasing strain acting upon the ITB.
Add to this the fact that dynamically, loading of the lateral hip will be increased in this position – the athlete will be experiencing increased strain acting upon the ITB, thus potentially stirring up quite a hornet’s nest (not-so clinical term!) local to the distal ITB.
What The Research Says
While running step width is not a widely researched topic, one study by Meardon et.al published in 2012 assessed the effect of step width during running on factors related to iliotibial band (ITB) syndrome.
Step width alters iliotibial band strain during running
Meardon SA, Campbell S, Derrick TR. Step width alters iliotibial band strain during running. Sports Biomech 2012;11(4):464-472
This study assessed the effect of step width during running on factors related to iliotibial band (ITB) syndrome. Three-dimensional (3D) kinematics and kinetics were recorded from 15 healthy recreational runners during overground running under various step width conditions (preferred and at least +/- 5% of their leg length). Strain and strain rate were estimated from a musculoskeletal model of the lower extremity. Greater ITB strain and strain rate were found in the narrower step width condition (p < 0.001, p = 0.040). ITB strain was significantly (p < 0.001) greater in the narrow condition than the preferred and wide conditions and it was greater in the preferred condition than the wide condition. ITB strain rate was significantly greater in the narrow condition than the wide condition (p = 0.020). Polynomial contrasts revealed a linear increase in both ITB strain and strain rate with decreasing step width. We conclude that relatively small decreases in step width can substantially increase ITB strain as well as strain rates. Increasing step width during running, especially in persons whose running style is characterized by a narrow step width, may be beneficial in the treatment and prevention of running-related ITB syndrome.
In short, this research suggests that modification of step width has the potential to positively influence ITB strain and strain rate, as well as hip adduction and internal rotation – all of which are factors which have been linked prospectively to the development of ITBS in runners. Runners who present with a cross-over gait pattern may benefit from working on slightly increasing stride width.
Runner’s Knee Rehab Resources >>
Free Resources [PDF]
As with everything else in running gait re-education, there is simply no one-size fits all solution. Not all runners presenting with ITBS will demonstrate a cross-over gait pattern, and not all of those who do will respond positively to step width modification. Changes to running gait are to be approached with caution, backing right off with run volume, then building up again slowly.
For those who do present with a cross-over gait pattern, I’ve recently seen good results with this method as part of a multi-faceted approach to gait modification. Factors such as running cadence and posture are not to be neglected, for example.
It is my opinion that the conscious cues used to slightly increase running step width will help to develop the new movement pattern and coordination of the corrected firing patterns. BUT this conscious (and eventually subconscious) change in athlete’s gait pattern will only be successful as long as the local muscular endurance of the hip abductors and external rotators will allow.
I’ve found the combination of resistance / activation exercises for the hip abductors and external rotators, “standing fire hydrants” (see the last exercise in the video below), and conscious cues for running gait width to be a great approach to modifying this gait variable.
When all is said and done, this potentially provides another intrinsic biomechanical intervention we can offer to runners who present with ITBS. I’m still experimenting with it as part of a biomechanical approach to rehabilitating ITBS… I thought I’d share my experiences and rationale.
As always, your thoughts and comments below are most welcome…
I overcame right leg ITBS with a protocol similar to what you discuss. It was very interesting in that I could bring on the pain simply by adducting my right hip. It was very 123 in that stretch of the right hip muscles equaled pain. The solution was becoming aware of getting my pelvis in neutral in the frontal plane and creating some strength and lots of endurance in the right hip abductors. The problem was resolved in maybe 3 weeks after onset.
This is so true and often overlooked or not given enough credit it deserves. Quite honestly, I see the cross-over strike cause many injuries. Not only can a cross-over strike be from insufficient glute activation, but we often see it with runners who have limited internal hip rotation. Keep the good articles coming! I am enjoying them very much.
Thanks for the post. It’s great seeing postural dysfunction being applied to running.
Was wondering if you had a moment could you shed your respected opinion on the following
– sure we’d agree many athletes struggle to stabilise the pelvis in the saggital plane, most notable leadding to an anterior tilt relative to the frontal plane
– in line with shirley sahramann, tfl becomes dominant not only through saggital plane motion, but frontal and transverse plane movement. In the later two, it becomes an agonist in abduction and ext rotation of hip due to the mechanical advatage afforded by the anterior pelvic. In theory this would lead to the construction of rehab that emphasised liberation of anterior thigh followed by hip abduction/external rotation with hips fully extended.
– when transfering mobility and strength gains to the neuromuscular demands of running, this highlights the importance if acknowledging/assessing motion from not just saggital plane but also frontal at a minimum.
This is theory and ofcourse I dont have you practical experience. If you are willing to share your thoughts it’d be greatly appreciated
Thanks for commenting. I completely agree that we must of course assess movement patterns in all three cardinal planes of motion – rather than in the sagittal plane alone!
TFL is definitely a key player in many cases of ITBS that I see in runners and triathletes. I’ve noticed that often in those who present with ITBS symptoms and increased tone in TFL, their early-to-mid swing phase appears to display a slight yet noticeable circumduction at the hip, rather than the predominantly sagittal plane motion we’d expect. This then sets-up the leg and foot to travel through late swing phase in a lateral-to-medial trajectory creating a cross-over stride pattern.
Thanks for your reply. Much appreciated.
Have a Merry Xmas and a happy new year
Great post. I’ve always logically assumed this may contribute to my IT soreness, but it’s nice to see the science behind the biomechanics and also recommendations to improve.
Fascinating! That makes total sense.
I struggled with IT band issues until I learned a bunch of exercises to reeducate my running form.
I have noticed this in my husband, who is a runner with ITBS. I told him once, literally, “you look like you’re running on a tightrope” and that I thought it was contributing to his ITB issues. I also noticed that his arms swing across the front of his body when he runs. The legs like to follow the arms, and if your arms are crossing the midline of the body, the legs tend to make a similar movement. I’ve heard of some runners having success with very light (1lb or less) hand weights to help the arms swing more vertically instead of across the front of the body – leading their legs to land more directly below the hip and widening the step width. My husband has been focusing on making sure his arms don’t cross in front of him and he has had a significant reduction in ITB pain. I agree the other work mentioned is important and helpful too, but thought the arm swing was also worth mentioning. Thanks for taking the time to maintain this website, it is full of great info!
I was able to recover from a strong ITB Syndrome that kept bothering me for almost 6 months. I tried all types of procedures attempting not to stop running. So a basically, stopped for 1 week, did the recommended physio exercises, sedative therapy and went back without being properly recovered. Finally after Buenos Aires Marathon (which I ran under the effects of a cortisone injection) I decided to take a good. As a triathlete I thought I could be able to cut the run, and continue cycling, but this indeed, I believe doesn’t work for the recovery. So, at this point I stopped running for almost 44 days, which for any runner, triathlete is an eternity. Came back after this period to do a serious strength workout routine for 2 weeks and after almost 2 months later the pain was gone, though, I kept that strange feeling in the knee, which is mainly psychological. Days went on, and finally it was healed after 8 months. Patience is definitively the key surpass thins injury.
A very interesting video. I have analysed my gait today as I have had ongoing (over past 3 years) re-current ITB issues. I filmed myself running and noticed a slight cross over gait but mainly the toe flick inwards that the female in the video is displaying. I only display this on my left leg (the always injured one!!).
Can I ask, in your comments you say this is down to increased hip adduction, could this mean an imbalance with adductor’s vs abductors? You advise working on the abductors but do not mention the adductor’s.
I have been working on my abductors for many months, which is helping but I still can feel I have a tight IT band, I have neglected the adductor’s.
Advice would be brilliant.
All very interesting and I am always hopeful to learn something from KR site but to be honest its completely riddled with Jargon and terminology that is in my view typical of elaborate restricted code used by health care professionals (I am one but more check up from the neck up!).
I’m not convinced that the average enthusiastic runner and even those I know that regularly compete would be able to synthesise some of the material and apply it to their running. I am sure that your intention is to help runners and don’t want to be critical but thinks its something to consider if you want to expand your sphere of influence…..jeeez I’m doing it now!!!
I think you under estimate the your patients.
I deal with musckuloskeletal injuries of the lower limb daily, many of which are runners.
Running, like many athletic pursuits is a lifestyle. Wity info so accessible with the internet these days, many people will research their ailments to quite a detailed level.
The best thing about James and a select few others is that he presents good quality, research and in the trenches evidence for injury management.
Always enjoy your posts James. I was wondering what your opinion on toe/foot inversion on push off was. It is quite prominent in this “Cross-Over Gait Running Pattern” video clip example. However, it also can also be seen just as pronounced in runners who don’t have an obvious cross-cover gait pattern. Your “Big Toe Extension & Running Gait” feature associates it to limited first toe (MTP) Extension. If MTP Extension is normal are there other mechanisms that you feel could cause this common toe/foot inversion pattern on push off?
I also believe the foot ‘flick’ into plantar flexion and inversion (very clear in this video) is connected to itbs. Pulling the fascial lines of the peroneals, fibula head attachments of bicep femoris and generally aggrevating the lateral knee tissues. Might be worth looking at dorsi flexion and eversion strengthening exercises. Would you agree James?
I’ve suffered from IT Band syndrome for couple of years and just been told I should give up running after an MRI confirmed ITB and no other knee problems. I had only ran for 4 years never getting beyond 1/2 marathon, and having to have several months off each year to recover from the pain.
I’ve tried physio which has strengthened glutes and hips, I’ve had sports massage, TFL release, had my feet checked and lastly steroid injections which made things worse, it now hurts to walk. I’m now at the end of the line, unless you can offer some help/suggestions !!