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.

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 Abstract 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.

Practical Application

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…

Last updated on August 21st, 2019.