The most commonly cited reason for stretching the iliotibial (IT) Band is to alleviate knee pain. Before we can state the best way to stretch it, we need to talk about what the IT band is, and then how it influences knee pain.
What is the IT band?
It’s imperative to note the IT band is not a muscle. I’m not sure if people realize this or not, but based on the way people talk about it, and talk about stretching it, I’m pretty sure people often think the IT band were like any other muscle.
It’s not.
Multiple muscles insert into the IT band. So rather than the IT band being a muscle itself, it is a band made of other muscles. The two big muscles comprising the IT band are the gluteus maximus (GM) and tensor fascia latae (TFL).
From Anatomy Trains by Tom Myers. (Get this book!)
It is crucial to understand the TFL and GM comprise different portions of the IT band. The TFL comprises the anterior portion and the GM the posterior portion.
Using the Anatomy Trains philosophy from Tom Myers, we can see while the GM and TFL insert into the IT band proximally (starting at the hip), other muscles insert into the IT band distally too (at the knee).
Credit to Anatomy Trains and Tom Myers
The anterior portion of the IT band connects into the tibialis anterior (TA) while the posterior portion connects into the peroneus longus (PL). Therefore, there is a connection between the TFL and the tibialis anterior, and another connection between the GM and peroneus longus. And all of these insert into one band.
How does it influence knee pain?
This is where it gets a little messier.
The most common cause of knee pain is an imbalance between all these muscles acting on the IT band. Specifically: the TFL is overactive and tight, but the tibialis anterior is underactive and long (remember these two muscles are connected on the anterior portion of the IT band). And then the peroneus longus is overactive and tight, but the GM is underactive and long (these two are connected on the posterior side of the IT band).
By looking at these muscles specific actions we can begin to figure out how pain arises. At the hip, the TFL abducts, flexes, and internally rotates the femur. It also laterally rotates the tibia.
Meanwhile, the GM has almost the complete the opposite effect: Hip extension, lateral rotation of the femur and some possible internal rotation of the tibia.
That is, the TFL and GM have almost completely opposing actions at the hip and knee. This is why most often when one is strong/tight, the other is weak/long.
At the knee: Peroneus longus pronates and plantarflexes the foot and has some effect on lateral rotation of the tibia.
The tibialis anterior helps to supinate and dorisflex the foot and internally rotate the tibia.
That is, the PL and TA have opposing actions at the knee and ankle. In fact, these muscles not only insert at the IT band, they actually form a band together at the bottom of the foot!
Credit to Anatomy Trains and Tom Myers (www.anatomytrains.com)
Again, indicating when one is strong/tight, the other is weak/long.
Remember, the TFL is dominant over the GM, and the PL is dominant over the TA. Therefore, in terms of movement, we have a dominance of internal rotation of the femur, a dominance of lateral rotation of the tibia, and a dominance of pronation and plantarflexion of the foot.
This imbalance at the IT band will make itself evident during movements like a squat.
This is overwhelmingly the predominant cause of knee pain for people. And this is why so many people are trying to stretch their IT band.
However, now we can tell just “stretch the IT band” is a poor remedy. We need to stretch the band in a very specific manner in order to get rid of our knee pain.
The most effective stretch is going to calm down the overactive muscles and wake up the underactive ones. We need to loosen the tensor fascia latae and peroneus longs, but tighten up the gluteus maximus and tibialis anterior. An ideal stretch will combine:
-Hip adduction (loosen TFL)
-Lateral rotation of the femur (loosens TFL and tightens GM)
-Hip extension (loosen TFL and tighten GM)
-Internal rotation of the tibia (loosen TFL and PL, tighten GM and TA)
-As well as ankle dorisflexion and supination of the foot (loosen PL and tighten TA)
Why most IT band stretches fall short
Now that we know what makes an ideal IT band stretch to help get rid of knee pain, we can talk about why some stretches aren’t good. Let’s look at some of the most commonly used IT band stretches:
Breaking this down:
-We have lateral rotation of the femur (good)
-Possibly some internal rotation of the tibia (possibly good)
-Hip Abduction (Uh oh –This tightens the TFL)
-A great deal of hip flexion (Shit –also tightens the TFL and actually stretches the GM. Opposite of what we want.)
-Ankle plantarflexion and no pronation or supination (This isn’t good, but, you could modify this to make it better)
This is actually a fairly good stretch for the posterior aspect of the IT band. But as we’ve dissected at this point, we rarely want this. I’d say at least 95% of people with knee pain / people who need to loosen their IT band don’t want to stretch the posterior part.
Don’t forget about the abdominals
Before criticizing another stretch, this is a good place to talk about the abdominals, specifically the external obliques.
If we agree a tight TFL is a common issue in those with knee pain (if you don’t, you’re wrong), we need to also look at how a tight TFL affects the abdominals. I don’t want to go into another treatise on movement at the hip, but suffice to say much like the TFL and GM have opposing effects on the hip, so do the TFL and external obliques.
That is, the TFL pulls the front of the hip down and the EO pulls the front of the hip up (so do the glutes). In someone with a tight TFL, not only will they potentially have weak glutes, but they will have weak EO too. The result is a lordotic posture:
Therefore, a common effect of trying to stretch the TFL is an associated lordosis. This is because the TFL is tight and doesn’t like being stretched, it’s “stiffer” than the abdominals, so it pulls the hip downward to try and lessen the stretch. Not something we want when we’re trying to loosen that sucker up.
This is my long way of saying when attempting to stretch the TFL -and IT band subsequently- we need to pay careful attention to how the hips and lower back are moving. Ideally, they aren’t. Realistically, they do. This is often a pain in the ass to get people to do properly.
We’ll come back to this. Keep it in mind for now.
The next stretch:
Breaking it down:
-We do have hip extension this time (Much better than the other stretch)
-We have ankle plantarflexion (Not good. But this could be modified in the stretch. Although it still wouldn’t be ideal)
-We have hip adduction (Good)
-We have either a neutral tibia or lateral rotation of the tibia (not good)
-Femur is either in neutral or medial rotation (Not good)
At least this stretch is targeting the TFL portion of the IT band and not the GM portion. However, there are other issues. Referencing the importance of the external obliques, remember how we want the EO to be stiff when we stretch the TFL / IT band to make sure we’re generating as good of a stretch as we can and we’re not achieving movement from the lumbar spine.
You can’t see it in the video, but I guarantee the girl has a lower back arch during that stretch. Look around the internet of people doing this stretch and you find this rather quickly:
Notice the arched lower back? While the TFL / IT band is still being stretched some, we’re not doing anything to concurrently stiffen up the abdominals. Next, due to the lordosis, we’re generating a bit of stretch on the glutes. Finally, we’re also promoting mobility at the lumbar spine. Mobility at the lumbar spine is a precursor to lower back pain.
While you could cue the person to squeeze the abs to prevent the lower back arch, I find people have a really, really hard time with this. They just don’t know when they’re doing it properly, the right way it should feel, etc. It’s like coaching a 40 year old virgin.
Sorry, doctor, but you sir do not have the “world’s best IT band stretch.“
The better way
Breaking this down:
-By making sure the knee does not fall out to the side we have hip adduction (Good)
-A tiny bit of lateral rotation at the femur (Good). More can be accomplished but I find this doesn’t influence the stretch much.
-By letting the leg fall to the ground we let gravity give us hip extension (Good)
-Internal rotation of the tibia from turning the foot in (Good)
-Ankle dorisflexion and supination by pulling the big toe up and in (Good). If you do this last, you’ll notice a difference in the intensity of the stretch between letting your foot fall to the ground (plantarflexion) and pulling it up (dorisflexion). Many people will exclaim they get a better stretch all the way up in the hip just by pulling the foot upward. Further evidence the dorsiflexion and supination is helping to stretch the TFL / IT band and the TFL and TA are connected.
Also, because of the self-feedback mechanism of laying on a bench or table, you always know whether or not your lower back is arching (in lordosis). Therefore, you are guaranteed to know how hard you need to be squeezing your external obliques to make sure there is no compensatory movement at the spine.
Next, by lifting the arms overhead we can also generate a nice stretch in the lats, pecs, and rectus abdominus (all commonly tight). Not really necessary for a stretch aimed at knee pain, but it sure isn’t hurting anything.
BOOM. How’s that for bang for your buck?
With that said, here are the common ways people may mess this up:
1) Letting the foot plantarflex and pronate
You HAVE to make sure your foot is not pointing down and out to the side.
2) Not fully contracting the abdominals
If you’re not feeling any stretch in your hip / thigh it’s almost guaranteed you’re not fully squeezing the abs.
Watch the difference in thigh position when the abs are fully squeezed and when they are relaxed:
Notice the thigh elevates, bringing the hip into flexion, each time the EO are fully contracting. This illustrates tightness in the TFL because when the EO fully contract and posteriorly tilt the pelvis, the TFL is put on stretch. And when it’s put on stretch you can see the tightness by the thigh being pulled off the bench.
One sure fire way to know whether or not your abs are squeezed tight enough is if you’re lower back is flat on the bench. If it’s not, you’re abs aren’t tight enough. It’s worth noting for those with a fair amount of fat on their body, and or lower backs, sometimes they give themselves the “feel” of their lower back being flat when it isn’t. It’s just that their adipose tissue is thick enough to give them that illusion.
If you’re watching someone, it’s best to look at the top of their hips. Do they look angled downward? Like an anterior pelvic tilt? Then the abs aren’t squeezed enough. It’s hard to describe, but you can spot it.
If you’re having trouble with your abs (this is just a sign they’re weak and not strong enough yet) grab your opposite knee and pull it into your chest. This will allow your upper body to help posteriorly tilt your pelvis.
Then you can progress to one arm holding the knee in and the other arm overhead:
And then to both arms overhead.
3) Letting the hip abduct
This will happen due to the TFL not wanting to be stretched and thus pulling the hip into abduction.
For some people adducting the hip to a certain point will cause them to feel pain / pressure in their knee. This signifies that when the TFL is on stretch, knee pain arises. This is verrrry common.
Simply only let your hip adduct to the point where you don’t feel pain. Over time as the TFL loosens up you’ll be able to adduct further and further.
4) Poor posture at the upper body
A lot of people may not be ready to put their arms overhead when they first start doing this stretch. Many just do not have the thoracic mobility yet (or EO strength) to lay their upper back and head fully flat on the bench. Look at the difference in head posture here:
By making sure the chin is tucked you help insure the external obliques are posteriorly tilting the pelvis and not the rectus abominus. When you have that forward head posture and thoracic flexion the RA is in a shortened position. We do not want this. We want to stiffen up the EO, not the RA.
One final note: Don’t expect to feel an insane stretch when you do this. It’s not like you’ll feel like your TFL or thigh is going to rip apart from such a good stretch. Be much more concerned with doing it properly. Often times the biggest thing people feel is a hell of a lot of abdominal work. This is good. Remember, stiffening up the external obliques will indirectly loosen up the TFL.
Hold the stretch for at least 30 seconds.
And I’m out.
Please note the “best” element of this stretch is meant to be a sarcastic play. Understandably, sarcasm doesn’t always land through text. There’s no one magical exercise or stretch for every situation. See the comments for more.
For a more comprehensive look at stretching the IT band see: 6 Exercises to Loosen the IT Band
For a look at meshing this with a running program check out: 6 Weeks To A Healthy 10k
Here are some related posts I’ve written:
- Standing version of the best damn IT Band stretch
- My visit to the Washington University in St. Louis
- Sleep positioning and knee pain
Finally, if you’re tired of sifting through information yourself, get one on one help.
KH
March 28, 2012
Thx. Interesting analysis. As a recreational runner with IT band issues, it is mind boggling how much is out there. I’d love to hear your analysis of this ITB/TFL/Hip Flexor/Quad Combo Stretch
[redacted broken link]
reddyb
March 28, 2012
Hey KH,
I’m not much a fan of that stretch. (For others reading, check out the link above.)
The stretch is internally rotating the femur which a huge no-no (see the analysis in my post). The TFL internally rotates the femur so in order to most effectively stretch it we need femoral EXternal rotation.
Because of this internal rotation, along with the position of the foot where the tibia is laterally rotated (again, a huge no-no, the TFL/IT band externally rotate the tibia, so we need INTernal rotation of the tibia), that stretch is torquing the hell out of the knee.
The foot is also plantarflexed.
The woman in that video is only addressing the IT band from the TFL perspective and not from the various other muscles that insert into it.
Lastly, the lower back is rotated AND extended. She is compressing the hell out of the lumbar spine. Why do this if it’s not necessary? Rotation-extension syndrome of the lower back is the most common cause of lower back pain. The last thing we want to do is promote this movement.
The biggest issue that woman is having, and this is very common with physical therapists and or athletes, is that because she FEELS a good stretch in the area of the TFL/IT band she assumes it is a great stretch for that area. It’s not.
There needs to be much more of a focus on the quality of movement from the TFL and IT band (this is where the abdominals come in) and not so much of a concern with feeling like the TFL is going rip in half as an indicator it’s getting a good stretch. If this worked the treatment would be pretty simple. This goes for foam rolling / self massage work too.
To make things more lucid: I would never have one of my clients come close to attempting that stretch.
Let me know if you need anything else. Hope this helps.
Allan Wetzel (@rehabscience)
September 10, 2013
This looks like it would be OK for some athletes, but would be far too difficult for those not in shape or for many receiving physical therapy.
reddyb
September 12, 2013
Well, I don’t train any athletes, I’d say my clientele has been roughly 90% above 40 years old, and I’ve had many in their 60s and 70s do this in some form. So, I’d have to disagree.
Update 9/26/15: I actually do train some athletes now. Started taking some on maybe 18 months ago, and have been enjoying it, in case anyone is interested-
http://b-reddy.org/2013/06/20/the-remote-client-process/
reddyb
March 28, 2012
And KH,
For your IT issues, start focusing more on strengthening the deep lateral rotators of the hip (glute max, posterior gluteus medius, etc.) and a bit less on the IT band.
I know this probably flies in the face of everything you’re finding online, but it’s what works.
ahandful4u
September 24, 2015
No link
reddyb
September 26, 2015
It’s an old one. Original author may have taken it down or changed it.
I actually train a few athletes now as well! So thing have changed some for me too.
marathonnh
April 13, 2012
Fantastic! I found your page looking for video for at stretch a PT gave me this week. It is the “World’s Greatest IT Band Stretch” you embedded above. I really appreciate that you give the reasoning for what is stretching and what is tight and how it all works together. I’ll have to keep reading this through to fully understand it, but you are talking about all my compensations and dysfunctions here. As a long time distance runner, my left side is a mess. I had surgery for a to fix a torn labrum in my hip last summer, but I have run with a funky stride for years. I have an inwardly rotating left femur (femoral anteversion) but my left foot rotates outward (tibial torsion?). I have tried all sorts of therapies and the new PT looks promising, but the stuff I have been looking at and wondering about on my own are referenced and put together here for me: such as my anterior tibialis and the effect on my foot and also my tight glutes ( have had trigger point injections). Thank-you for describing how all these muscles work together as a unit to pull the body apart rather than just looking at each muscle seperately. I will be trying your new IT Band stretch.
reddyb
April 16, 2012
Hey marathonh,
Thanks for the words, I appreciate it.
Keep in mind that just because you have an internally rotated femur does not mean you have femoral anteversion. While many times this is the case, and is more often found in women than men, it’s not always.
Look at this girl’s right knee and you can see a test for femoral anteversion as well as a girl with femoral anteversion to a severe degree: http://www.youtube.com/watch?v=md_Sqxl3tfw
Are you sure you have tight glutes? If you have an internally rotated femur you almost assuredly don’t have tight glutes. You may have trigger points there because the glute muscles are locked long. Meaning they are actually “loose” / not tight enough!
Let me know.
marathonnh
April 16, 2012
You are correct. I have trigger points in my glutes. I have had a series of injections for them a couple of months ago. So that means they are loose not tight, hmm?
This is why I like your writing here. You explain things as a whole, not as isolated body parts.I have been to so many doctor’s, PTs, chiropractors, podiatrists, ect. in search of how to recover my running stride. I have been to top-notch people, but I never get the full picture of what is going on. I get bits and pieces that I have to put together myself. Your post explained so many of my problem areas all in one package. I am told I have femoral anterversion. Who knows? I have been told I have tibial torsion. Who knows? I find it wierd to have both on only one side and not the other. Something else could be going on here. I am determined to get it straightened out sooner or later.
Btw, I noticed the video that someone else posted from Leigh at Athletes Treating Athletes in the comments above. She was my PT before my surgery and then a few months after. She did a great job calming down tight hip muscles before I had surgery with hands-on work and we were making good progress after, but time ran out.
Keep up the good work and writing. I will be reading and learning.
reddyb
April 17, 2012
It’s really important you find out whether you truly have anteversion or not. And if you have somebody who actually knows what they are doing they should be able to tell you rather quickly. Like in 90 seconds.
I will say, If you have true anteversion, and you are a severe case, running may never agree with your body.
In these people typically pain starts for them very young though. Like in their teens, or early 20s at the latest. (Not sure when yours started.) If your pain set on later in life, I doubt this is enough of an issue for you for it to be the primary cause of what’s currently going on.
If you can send a video of you doing the anteversion test I may be able to help you out.
Where are you located? I may know someone in your area who can help you out as well.
Lastly, if you find someone who knows what they are doing they should be able to give you some pain relief within your first session with them. And then it should take them MAX a month for you to notice considerable improvement overall. If it takes longer than that they did something wrong and or they don’t know what they are doing.
marathonnh
April 17, 2012
I ran competitively in high school and college (nothing great) and started doing marathons in college too. I always had a somewhat funky stride on the left side, but nothing that had me injured or in pain. After college in my early 20’s I jumped into triathlons (it was 1983-there was no sports medicine-bike fit-coaching). I did an Ironman as my 3rd triathlon after only a few months of training and was heavily involved with that for 5 years including 5 Ironman distance races, but I could barely stand up by the end of that (left lower back pain-probably due to how I set my bike up for my leg and hip. I rotated the left cleat out for my leg as well as constantly rotated the saddle left or right to get comfortable and I think that jammed my hip into the socket- but I felt the repurcussions in the lower back which tried to do all the work). I was always in discomfort for years despite running all the time (50 or so marathons). Once I started looking for a way to fix the pain and stuff with different therapies the back got a lot better, but I have always been off on that left side and never really pain free (even though I kept running-usually it made me feel better) until it all fell apart a couple or years ago and I finally had surgery for the labral tear.
Now I feel pretty good in general, except the left side is awkwardly off like you descibed in this post. I am really not in pain. It just goes off with exercise so I know I am doing something wrong and definitely not doing something right. I have a new PT and I hope to bring up your post and ideas on the muscles. I was recommended by The Gait Guys (online) to see this guy here who wrote a book on gait mechanics http://www.newtonbiomechanics.com/pages/about-us last December and he did tons of observations, tests, and measurements and he said what a physiatrist had told me earlier that I had femoral anteveriosn as well as the tibial torsion that others had said. A week after that I went back to a well known podiatrist [broken link redacted] and he did manipulations on me ( and basically said “bah” when I mentioned femoral anteversion) and the 40 degree tibial torsion seemed to go down to less than half after that visit. That helped for a few months and I was slowly getting up to a couple of 40 mile weeks and the dysfunctions came back. I went for manipulations again and they did not work. I do think he missed one. So I think like you wrote that there is an underlying structural thing, but then the muscles add to it and it gets worse.
I am working on somatics to improve my movement (doctors kept telling me I had to retrain my brain to get rid of bad movement patterns without telling me exactly how to do that). The new PT is targeting my hips and I guy a talked to at the Boston Marathon this week (he is considered one of the world’s best adventure racers) told me to do one-legged squats (left leg is really wobbly) , start out running one mimite per day and add one more minute per day but make it right.
I am in southern New Hampshire about an hour from Boston. I travel almost an hour to the the new PT and also to the last one. If you know someone in the area who listens, looks at the whole body, and explains stuff, please let me know (or let me know if you ever come to the Boston area).
I am taking too much of your time, but here is a short gait video taken Saturday at the Boston Marathon Expo where my leg looks better than it usually does. It is much more even, but if you look closely the left foot does turn out some and the pressure is more on the inside of the left knee which doesn’t pull back evenly like the right side does. I was actually happy to see this video as I have looked much worse before surgery with the knee knocking in: http://www.youtube.com/watch?v=L4-rcQuMUDg&feature=player_embedded Because the left side is wonky and unstable, I feel it up in the hip joint where the femur seems a bit off and rotated in the hip joint. I don’t want to hurt that hip joint again.
This is why my blog is called Recover Your Stride. I will be featuring your post soon on the blog as I like your explanations. I have been all over the web and you explained a lot in ways that no one else really has (that I have found).
Thanks,
Jim
reddyb
April 18, 2012
Hey Jim,
First, thanks for posting this over on your blog. I appreciate it.
Second, I saw you talking about glucosamine a bit on your blog, I wrote this if you’re interested: http://b-reddy.org/2011/09/01/glucosamine-and-chondroitin-for-knee-pain-treatment/
Third, knowing you’re a male, I should mention anteversion is very uncommon in males. Retroversion is more common in males, and anteversion more so in females. In fact, I can only think of one male I’ve trained who had anteversion. And his was IMMEDIATELY apparent.
Then, like I said before, if you have run that seriously for that long, I highly doubt you have an anteverted hip. OR, if you do, it’s not very much.
For example, the people I’ve had with true anteversion (male and female) knew that running did not agree with their body at like 12 years old. It was never something that set on later in life. Doesn’t mean it can’t happen, but I haven’t seen it, and I really doubt this is happening with you).
Next, if you had someone who could decrease your tibial torsion through manipulation, then you don’t have tibial torsion. Remember, things like anteversion and torsion are structural maladaptations. That is, they can’t be corrected. For example, if you have someone who claims they decreased your anteversion or torsion you should be asking them, “Oh yeah, so how did you change the structure of my BONE???”
If you had tibial lateral ROTATION that was decreased, then we’re talking about muscle imbalances. And muscle imbalances we can change / improve.
My best guess without seeing you, but something I’m still confident in saying to you is: I bet a lot there is some dysfunction going on with your left glute max and glute medius as well as the external oblique. Your issues with a single leg squat further corroborate that.
The overwhelming cause of hip pain I see, and that’s common in runners, is femoral anterior glide.
I’m not sure if you’ve come across this in your research, but a quick explanation is the hamstrings and lower back become the dominant hip extensors while the glutes are not working properly as they should. Because the glutes attach directly onto the head of the femur while the hamstrings do not, the glutes are never pulling the head of the femur nice and tightly in the socket. Thus, the “femur glides anteriorly.” (The glutes aren’t helping to pull the femur backwards. There is insufficient posterior glide.)
You’ve mentioned your foot is prone to turning out when you run, and like you said, it’s really not bad in that video, but it is there some…this is also common with glute dysfunction. The femur rotates inward, thus the feet turn outward. And, like mentioned in this post, this glute dysfunction is directly related to issues with the ITB.
Something to remember is that just because your gait looks decent in that video does not mean things aren’t happening as you get fatigued. Often times issues don’t arise until the person gets tired and then reverts back to all their old habits.
Finally, while all of these stretches and manipulations can be beneficial, part of correcting issues is correcting the nervous system. That is, you need to correct the specific movement that is causing you pain.
So while doing these stretches / manipulations may make you more likely and make it easier for you to run “correctly,” you still have to consciously…run correctly. This is NOT easy. But it’s necessary.
My best guess for you right now (feel free to shoot me more info!) is you need a crapload of glute max, glute med, and external oblique strengthening, coupled with cues such as “squeeze your glute every time your foot hits the ground” while running.
Take a look and see if your glute on your problem side is smaller than your other. And see how your external oblique fairs compared to the info in this post: http://b-reddy.org/2011/09/12/3-common-weak-muscles/
I know of a few guys in the Boston area. I’ve worked at Cressey Performance which has two guys, Eric Cressey and Tony Gentilcore, who are top knotch. (However, I have not been there in years, so keep that in mind.) Issues like the above should be some things they would spot very quickly. They run a primarily baseball facility now but they are in the Boston area and are thus well acclimated to the endurance community.
The other guy is Mike Reinold. I don’t know him personally but he is friends with Cressey and his information is top knotch as well. I’m also not sure if he accepts outside clients (he works for the Red Sox).
Eric and Tony run a private facility in Hudson so they would be able to easily see you. At least that’s how things were when I was there.
Eric: ec@ericcressey.com & ericcressey.com
Tony: tonygentilcore.com (contact form on the site)
Mike Reinold: mikereinold.com
reddyb
April 18, 2012
FYI Jim, I emailed Tony and Eric so they’ll know who you are if you contact them.
marathonnh
April 18, 2012
Thanks again Brian,
I saw my surgeon today and he says my hip is good and should stay good. The PT exercises I got today are OK-working on the tight hip, but I am not sure he likes that I get ideas elsewhere and that I have questions. Plus he was supposed to be the “runner” PT, but I think he wants me to set a long term goal of being able to only run 1 mile on my runs and doing that 3 days a week. No, I want to do marathons againsome day-if possible.
I have to read through more closely what you wrote. I asked a ART chiroprator about femoral anterior glide a couple of years ago. It was the last thing I tried to rule out before thinking I had a torn labrum in my hip. He didn’t know about it and I didn’t understand it enough, but I have heard of it.
And yes, correcting the nervous system is something I have been told to do without being told how exactly. That is how I learned of Feldenkrais and Somatics and before that Z-Health. Other than that the only thing I think applies is putting yourself in a wobbly position (lunge on a wobbly surface) and try to hold yourself properly while the muscles shake an quiver.
Yes, I have heard about Eric Cressey. I have his book and mobility DVD. I read his articles and watch his videos at times and recall him getting into postural restoration (I had a PT do that with me to some extent a few years ago and found it interestingly mysterious).
I will have to check him out to see what he offers for the average athlete. I know he usually works with all sorts of pros and high school and college athletes. I will check out the other guys too.
What I wanted to ask you is about your inspiration. You mention Anatomy Trains which I have read many poiitive things about from people who write about the body. Is this an accessible book for a non-professional to read or would it just go over my head? Is there an accessible book that takes Thomas Myers concepts and shows you how to apply them? I hear good things about Shirley Sahrman books. Are these the type of resource that puts everthing together. You take the concepts and talk about how the muscles work together in function or dysfunction. Not many people do that, that I can find. Maybe you need to write a book! My new PT may end up super in the end, but he doesn’t try to teach the why of what he wants me to do. After I realized, he didn’t like hearing about other people I have talked to this week, I finally just said, “So what your are saying is the TFL is tight and the Gluteus is weak and…. and I used the things you have written about in this post and he said, “Yes, that is it.” Sorry, I couldn’t give you credit as he didn’t like that I got information and ideas from other people at the Boston Marathon Expo (one legged squats and starting at a minute of running and adding one minute per day. He may be right about things in the end, but he doesn’t want me to run or do the squats just yet.
Anyhow, I just put up some pictures of my consistent running form over the past 30+ years and I hope you can see the what I mean by the knee-knocking in, the foot twisting out, and the knee caving in. I am amazed at how it hasn’t really changed in all those years. If you are curious it is here: http://recoveryourstride.blogspot.com/2012/04/bad-stride-following-poor-running-form.html
Thanks again for your thinking and for the recommendations,
Jim
reddyb
April 21, 2012
Congrats on the good update from your surgeon. That’s surely a good thing.
Let me know what exercises your PT gave you. I obviously don’t know this PT, but I will say this: 1) Most PTs are AWFUL at what they do. I cannot emphasize this enough. 2) Anyone who is not open to listening to things from their clients is someone I’d be wary about. At the very least he should be open to hearing your thoughts and should be able to have a well thought out rebuttal to any of your points should he disagree with them. Enough of a rebuttal that you understand why what you think could be wrong (if it is).
The wobble board stuff for a hip injury is futile. There’s just no need. Furthermore, I would bet a lot you have issues just standing on that left leg in a proper position on stable ground. 1) You’re not ready for a harder progression and 2) There really is no point in a wobble board for you right now.
While Eric works with a lot of pro guys, don’t think he doesn’t work with rec athletes. The majority of his clientele is high schoolers and non-pro guys. Tony is more familiar with your demographic as well.
Anatomy Trains was a very, very hard book for me to get through. Myers writing is just not friendly to me. The information is outstanding, and it can truly change how you look at things, but I’m someone who knows my anatomy very well, and knew it very well before I read this book, and it was still excruciating for me to get through.
Shirley Sahrmann’s work is bar none the most influential for me. And honestly, nobody comes even remotely close. I cannot emphasize the significance her first book had on me. I wrote a little review on the “What I read” page here: http://b-reddy.org/what-i-read/ (Her book is under the “Movement” section).
In short, her book is fantastic, but it is not an easy read either. I found it much better than Anatomy Trains, probably because it resonated with me more, but it was still not easy. Keep in mind though I know that entire book pretty damn well. You may be able to read just the section on the hip and make some headway.
Another thing to keep in mind though is I was able to learn dynamically while I read these books. For example, I could read some issues related to the hip from Sahrmann and then 30 minutes later put it into practice with a client who came in. This made things much, much easier for me. A lot of reading Sahrmann’s book is trying to visualize the movements she is describing. It is much easier to visualize things when you can see someone do it in person over and over!
Some other tie-ins:
-After looking at your photos, I agree with your therapist in that you probably should not be doing single leg squats right now. Again, I haven’t seen you, but based on your photos and my experience, you are likely no where near ready to do that hard of an exercise. The first progression for you would be trying to stand on one leg without the knee rotating inward or the hips rotating / dropping (see below).
-I saw you mention a few things regarding orthotics. They’re not going to get the job done for you. Your issue is starting at your hip, thus you need to correct things at the hip. Correct things at the hip and the issues at food will resolve as well. Whereas the reverse is not true.
-Look at this picture again: http://4.bp.blogspot.com/-lpTm9mSw8ks/T4-DAzn2dNI/AAAAAAAAClo/EWzviBtzwMA/s1600/running8.jpg
Now look at your left hip and left shoulder. Notice how they are closer together than the right side? Notice how your left glute / hip is kind of sticking out to the left side? This is classic tibiofemoral rotation syndrome (your femur is internally rotated and your tibia is laterally rotated). Because your glute medius and other hip abductors are so weak your knee caves inward, and the internal obliques are performing extra work (this is why your shoulder and hip are closer together on that side -the internal oblique is short / stiff / performing too much work) and the hip abductors are not strong enough to perform the work they should be doing.
The lateral rotation of the tibia is really prominent during knee flexion. This would be where you comment on how your foot is “out” when it’s bent behind you. As per this post, that is likely due to an extremely tight IT band.
Honestly, I see a “you” every day. Hell, Holly (the girl in all the videos and pictures above) is EXACTLY you. I really don’t see anything unusual with you, at all. (Of course doing things in person can potentially be different.)
It bears repeating: I just highly doubt you have femoral anteversion or any true structural issues. Keep in mind, just because you’re having issues with femoral internal rotation does NOT mean you have anteversion. In fact, many males can have femoral internal rotation and have a RETROverted hip.
So, you ran pain free for a ton of years, you’re male, you have narrow hips (anteversion is more common in females who have wider hips)…I would just be shocked if you had anteverted hips. Every now and then I see something I haven’t seen before. But, at this point, based on what I see so far you’re probably in the majority side of the clientele I have i.e. all very, very common issues. In fact, I see your issues in my clients more often than I see clients who don’t have those issues!
In one respect this is good, because it can be corrected. In another, you should have found someone who could take care of these issues by now. That’s not a slight on you, it’s a slight on the profession.
Hope this helps; hope that all makes sense. (I typed this up quickly.)
Shoot me some more info on what you’re doing in PT. And thanks again for the words. I have many book ideas in my head; the knee and hip are on my to-do list. Unfortunately for you, the elbow will actually be my first one :).
Oh, and I would definitely keep trying to make your PT explain things to you. This will help you find out if he knows his stuff or not. If he can’t rationalize every, single, thing he has you do, then there is an issue. And I do mean every single thing.
marathonnh
April 24, 2012
Thanks for another reply,
The PT seems to be working so I will go with it. I feel better reading your post and understanding what he is trying to do, although I may see if he can send me to someone closer to my home. He is almost an hour away for a 30 minute PT session and he is very busy so I can’t get appointments as he heads up the department at the hospital. I go in tomorrow and then not until the middle of May if something doesn’t open up!
I am doing side leg lifts with a straight knee, the IT band stretch he assigned-but also your stretch. I feel his stretch on the outside of my knee. I am also doing a figure 4 stretch (on belly- small ankle weight- let it pull down the left leg (which is up 90 degrees from the knee) towards my right side. He does this while also pushing on my femur and I think this has been the most important thing for my hip. If loosens up where I have been tight since the surgery. Last week he added bird-dogs and a one-legged stand where I pull an elastic band toward my hip while maintaining stability. I am not doing single legged squats as the PT nixed those too.
I ditched my orthotics this week and am working on somatic stuff on my own to strengthen the movement of my feet. It feels good!
I am happy that you think things don’t look structurally wrong with me. I hear so many things. I do notice my leg straightening out again to a better position while standing and walking so something is going right. I just refuse to run at this point until I am ready. However, this week I took out my road bike for the first time in a year ( I have used my mountain bike) and cleated in to the same position I have had the bike for many years. I did Ironman triathlons on this bike in the 1980s and I must say the hip surgery has worked wonders. I could never bike without discomfort. Ever. I could never get settled or even on the saddle. My left femur or something use to push into the saddle so it felt like the bones of the left side were forward of the bones on the left. Not anymore. Every year when I started cycling on that bike I would be in discomfort within 2 miles and want to get off it a few miles further. This time I cycled 22 miles without a moment of discomfort or pain! It was amazing. I never knew cycling could feel so good and easy. Part of it too is the orthotics. My feet always hurt no matter what I tried (even other orthotics) until I got this pair two years ago so they are good for something! With the orthotics and the hip surgery, I can be a cyclist again! Now to running. I refuse to run until I get these muscles properly strengthened so I can run with as much ease as I felt on my bike. I hope to surprise myself and a lot of people when I finally get running again.
Thanks,
Jim
reddyb
May 3, 2012
Hey Jim,
Sorry it took me so long to reply. Sounds like you’re doing fairly well. How have things gone the last week or so?
Joe D
May 3, 2012
I have pretty bad tightness in my upper ITB, where it passes over the greater trocanter (actually had release surgery but am still dealing with tightness and inflamation). I have been trying this new stretch and just don’t feel it at all. I am pretty sure I have the technique right – is this stretch focused at the lower (near the knee) part of the ITB? Maybe this is why I don’t feel anything where my specific tightness resides?
Great blog, btw – just added to my RSS reader.
reddyb
May 3, 2012
Hey Joe,
Shoot me some more details on your surgery. How long ago was it done?
This stretch focuses on the entire IT band. In actuality though, the stretch above is aimed at stretching certain parts of the band BUT tightening up other parts concurrently.
First, usually when somebody doesn’t feel it they are doing it wrong. The most common thing people forget is to dorsiflex the foot.
Next, everyone feels the stretch in different areas. For those with a history of knee pain, some will feel pressure down at the knee (often times the patella). This is indicative of a tight IT band as the tension is pulling on the knee cap causing some pain.
Others feel it down the front of the thigh / hip.
Others who are fairly weak in the external oblique (abs) feel the abs working a ton and not much of a stretch. This doesn’t mean they aren’t stretching the band though. It’s just that they are so focused on the abdominals the stretch doesn’t really register mentally. If that makes sense.
Of course, you may not actually be tight in the IT band either.
Take a look at some of the pictures above again. You’ll see how the thigh isn’t touching the bench in many of the pictures. This indicates the TFL / IT is tight since it is holding the hip in flexion.
Again, you’ll see people where their thigh is no where (!) near being flat on the bench but they still don’t feel a massive stretch. This is despite the fact they absurdly tight in the band, and are clearly stretching it.
Finally, when I cue people on this stretch I tell them, “You want to feel your back always flat on the bench, some work in your stomach, and a bit of a stretch down the thigh.” It’s as much an ab exercise as it is an IT band stretch. Most IT band stretches ignore the abdominal aspect. So while you may feel more of a stretch doing these stretches, they are often pretty futile. (The abs are still weak and haven’t been strengthened.)
Hope this helps and thanks for the compliments on the blog!
Victor (@victorblomma)
May 16, 2012
Hello love your post, have had knee issues for about a year know, it just arose from a tough thing at work (military). Whats happening is that its like my femur is being pulled inward upon running, and even walking. And the foot on the “damaged” leg had started to pronate. When doing a hip flexor/tfl stretch the pronation sudenly disapairs and my femur is being externally rotated a bit more. Could it really be that the TFL, Hip Flexors is so strong that it rotates my femur in while standing up?
Another thing when im lying down flat on the back, my leg externally rotates (didn’t do that before) And hip internal rotation is really bad aswell.
Sorry for my long post, and as you notice english is not my native language.
reddyb
May 16, 2012
Hey Victor, thanks for the words.
It can definitely be the TFL is too strong and is overpowering your hip EXTernal rotators. This is very common.
How are you assessing your hip internal rotation? In what position?
Victor (@victorblomma)
May 16, 2012
Found an intresting read in the book Sports Injuries: Causes, Diagnosis, Treatment and Prevention. “Excessive femur anteversion can be a result of a tight TFL”. Is this really so uncommen that the two diffrens physical therapist i´ve met don’t know about this :S ?
reddyb
May 16, 2012
I’m not familiar with that book so keep that in mind.
Anteversion is a structural issue. That is, it is bone related, not muscle. So it’s a result of bone formation not a result of a tight TFL.
The only way I could ever see a tight TFL causing anteversion is if at a very young age a person had serious TFL issues and their bones formed in an anteverted manner during development (like adolescence).
For most people though, anteversion isn’t their issue. True anteversion in the hips is rather uncommon. Especially in males.
All I will say about your physical therapists is in my experience most PTs are rather awful at what they do. (This is true for the personal training field as well.) It’s rather sad.
marathonnh
May 16, 2012
Hey Brian, My PT is going well, even if only for 1/2 hour once a week. The key thing I get is the mobilizations for the front of my hip (a figure 4 stretch lying on the belly and some really deep hip flexor stretches)and some psoas release. I have not run for 5 weeks now per PTs instructions. With the mobilizations, stretches for the IT Band, and strength work for the glutes, I notice my left leg and knee lining up straighter (rather than inwardly rotating). I asked if maybe my “femoral anteversion” was more tight muscles pulling on my femur as Victor mentions above. I didn’t get an answer as he said that wasn’t important, but I am anxious to see what happens when I start running. I still have what looks like tibial torsion on that same side, but it doesn’t seem as bad as previously. It will be interesting to see how it all shakes out. I have been biking with good success and riding my kickbike (adult scooter) as well (up to 16 miles) and my leg has much better motion, straighter positioning, and strength. I refer people to this post when they ask about IT Band or hip issues.
reddyb
May 19, 2012
While I am really surprised your PT said anteversion wasn’t important, it’s great to hear some things seem to be working for you.
Definitely keep me updated. I’m interested to see your progress. If you can find any pictures or videos of this hip mobilization you’re talking about I’d love to see it.
Thanks a ton for referring people to this. I’ve gotten a good amount of traffic from your blog as well and I really appreciate it.
Victor (@victorblomma)
May 17, 2012
Thanks for the replies, yes I know I don’t have “true” antieversion, but the tight hip flexors make it look like I have anteversion. Im noticing my internal rotation is very poor lying prone on my back, trying to rotate the femur inwards, it just doesnt work very well but it does on my “healty” leg. There another thing that I do that i cant describe but there it’s really noticable. And I cant do one legged squat, http://www.maloneyperformance.com/Blog/wp-content/uploads/2011/09/Position-of-no-return.jpg thats whats happening, kind of.
reddyb
May 19, 2012
If that picture in your link is what’s going on, you are basically a perfect case example of what I talk about in this entire post.
As far as your hip internal rotation, it’s really hard to know what exactly is going on with this without seeing you perform some of the tests. I really wouldn’t worry too much about this though.
The important thing is to stop letting your knee move like that picture! A single leg squat is likely way too hard for you right now. I have people just begin with single leg standing, and this is often plenty hard enough for them. In fact, a lot of times they have to hold on to something just so they don’t fall over. If merely standing on one leg is this hard you can imagine attempting to squat is pointless. They are no where near ready for that progression yet.
Thanks for the link to the book too.
Victor (@victorblomma)
May 17, 2012
http://books.google.se/books?id=SPEWfSPseQUC&pg=PA55&lpg=PA55&dq=Sports+Injuries:+Causes,+Diagnosis,+Treatment+and+Prevention+femoral+anteversion&source=bl&ots=gMFY_kaYQh&sig=JQ2NyAd02pbRQyvJPYlfS81SJ4c&hl=sv&sa=X&ei=E6y0T5b8E4T64QTaprG5Dg&ved=0CGAQ6AEwAA#v=onepage&q&f=false Heres the chapter in the book.