Running after a hard cycling leg is no easy task and most triathletes start the run with heavy, sluggish legs. Subsequently, this final running portion of the triathlon is for many, the most difficult. Unfortunately for many it’s quite literally the most painful portion of the event as most injuries are a result of the miles run on roads, track and trails, with a staggering 70% of runners experiencing an injury in a given year.

For the runner, the hamstrings and glutes are the engine that propels the body forward with every stride. Keep that engine tuned and you’ll look good in jeans and run better, but ignore that advice and a great deal of research suggests that neglecting the hamstrings and glutes can lead to increased risk of overuse injury.

Of those overuse injuries, iliotibial band pain is the second most common knee complaint among runners and the most common lateral knee problem. The iliotibial band, or ITB for short, is a broad thickening of connective tissue that runs down the outside part of the thigh. It connects the lateral hip muscles to the lower leg, inserting just below the outer knee. The ITB is most susceptible to irritation as it repetitively frictions over the end of the prominence of the upper leg bone or femur.

Running in the same direction on a track, downhill running, leg length discrepancy, a “bow-legged” alignment of the legs and higher weekly mileage can all exacerbate ITBS (iliotibial band syndrome). Weakness of the lateral hip muscles (hip abductors) is also associated with ITBS as inward rotation and collapse of the thigh during the running stride creates an increase in ITB tension. Although more commonly found in runners, ITB syndrome can also be caused by improper bike position (saddle too high, misaligned cleat, etc.) or an excessive amount of miles.

The symptoms of ITBS are on the outer side of the knee, just above the knee joint or on the outer side of the hip. They typically occur shortly after the beginning of a run or ride and manifest as a sharp, burning pain just above the knee. Symptoms often fade after exercise, but in more severe cases, pain is present during everyday activities.

Now the old standby of foam rolling and hip stretching, while still useful, may not be enough to resolve the problem. The reason? The ITB is a very dense band of connective tissue that doesn’t easily stretch out and what’s more, recent research suggests that ITB tightness may only be one part of the problem.

So how do you get rid of pesky ITB pain? Hint: you’re sitting on it. Research in the Clinical Journal of Sports Medicine by Dr. Michael Fredericson of Stanford University compared the hip strength between the injured and uninjured side in runners with and without ITBS and found that hip strength was significantly lower in the runners with ITBS than in runners without ITBS. Subsequent rehabilitation focusing on hip strengthening, specifically lateral hip strength, was successful in returning the almost all the ITBS sufferers to running after 6 weeks.

Additional 2010 research presented in the Journal of Orthopedic and Sports Physical Therapy confirmed the altered mechanics caused by weak hips places an increased stress on the ITB while running, possibly leading to injury.

As with other overuse injuries, when ITBS strikes, a temporary halt in running is in order. As cycling can also be linked with ITBS it’s also important not to respond to the reduced running mileage by going hog wild on the bike. While ITB pain usually resolves with a conservative program of hip and leg strengthening, if left unchecked it can become a chronic and debilitating injury that takes months not weeks to fade. The key components of ITBS rehabilitation are; lateral hip and glute strengthening, quad strengthening, deep tissue massage/foam roller and activity modification/cross-training.

A word of warning to the uninitiated, the process of “releasing” the ITB by rolling across the outer part of the thigh on a foam roller is extremely uncomfortable for the first several weeks, at which point it gets tolerable. Researchers also suggest that, as the problem seems to be caused by friction of the ITB over the underlying bone, deep tissue massage or foam rolling should avoid direct pressure over the sore area, instead focusing on the upper portion of the ITB.

When the symptoms of ITBS have diminished and it’s time to resume running, a running stride analysis with a trained sports medicine professional is a recommended step before ramping up the mileage, lest the problem reoccur. Of course the best remedy for ITBS is not to get it in the first place and the same hip strengthening program used to treat the problem can be can be used to prevent it.

As with all overuse injuries, it is important to prevent ITB problems from reoccurring. Triathletes can greatly reduce this chance of injury by avoiding excessive mileage and intensity and utilizing regular rest days. For this reason, many consider recovery the “fourth discipline” of triathlon.

Try these exercises to help prevent IT band tightness:

3-Position Hip Abductor
Purpose: strengthen hip abductors
Repetitions: 10-15 repetitions in each of the 3 positions without pausing. Repeat for total of 3-4 sets on each side

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Bridge/Single-Leg Bridge
Purpose: strengthen glutes
Repetitions: 3 x 20-30 repetitions; for increased difficulty try single-leg version, 3 x 10-20 repetitions

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Leg Press
Purpose: strengthen quads, hamstrings, glutes
Repetitions: 3 x 8-12 repetitions

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Ian McMahan is a San Francisco based athletic trainer and freelance writer with a Master’s Degree in Exercise Physiology.