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Thoughts on Ilotibial Band Syndrome

We normally don’t insert ourselves into specific medical conditions because that is the realm of the medical professional.  But I will make a partial exception here for the common running injury known at Ilotibial band syndrome (“IT BS”).  Why?  ITBS is not like other injuries.  Unlike torn muscles or broken bone, the pathology of ITBS can be nebulous.   Superficially it may present as swelling, but not always.  MRIs on symptomatic patients generally show swelling in the bursa between the ilotibial band and the lateral femoral epicondyle (Muhle 1999), although the exact etiology is unknown (Strauss 2011).  Despite years of study, there’s still a lot of guesswork in this area.  Many times the recommended solution is “just stop running for a few weeks,” which as we know is an unacceptable answer during a competitive season.  Regardless of the medical treatment, many runners struggle to bridge the gap between treatment and performance, which is why we're firmly without our scope of practice to address this issue.      

I’ve had the fortune of having severe ITBS twice in my running career.  I say “fortune” because in retrospect, these experiences have created a valuable perspective.  You know you’re a rehab geek when you take scientific interest in your own previous injuries! 

ITBS came early in my running career before I knew what the injury actually was.  I obviously got better, but it took several months and ultimately resulted in a six year partnership with orthotics, that I ultimately weaned myself away from.  Second time occurred in my first run after a significant marathon PR.  I ultimately missed three months of running.  Such was my worry about a relapse that the foam roller travelled cross country to our wedding…a good six months after symptoms first occurred!  Great that the symptoms got better, but the rehab process should not be that long.  Given all the people running with Patt Straps and who constantly seek magic footwear remedies, the rehab process never ends for some. 

Common thinking is as follows…

·         IT band rubs against lateral epicondyle

·         Friction results in swelling

·         Swelling results in pain. 

·         Adhesions form along IT band that stick the band to the quadriceps, which prevent the IT band from gliding with enough space from the lateral epicondyle

·         Treat with ice on the swollen area, aggressive manual therapy to “break the adhesions,”

·         Lots of stretching to lengthen the IT band, hip exercises to strengthen weak lateral hips, orthotics or new shoes (or NO shoes) to address biomechanical issues. 

As we’ll discuss further, there are truths within each of these explanations and remedies, but refining our thinking of these mechanisms can help accelerate the convalescence and prevent athletes from chasing down dead ends, particularly with boutique manual therapy methods that promise resolution of symptoms without addressing causes. 

Let’s start with concept of friction.  Recent study has shown that compression of the fat pad beneath the ilotibial band, and not friction with the lateral epicondyle itself, may trigger of symptoms around the knee (Fairclough 2007).  For most runners, this is can be a relatively inconsequential difference (all that matters is my F$% knee hurts!), but it becomes more important as we try to understand hip mechanics, and ultimately to ensure you’re spending time and money on the right treatments.  It’s not my place to evaluate the treatments themselves, but it is important to ensure everyone has the right thought process before wailing on the IT band with a set of hands and/or the foam roller.    

Whether friction on bone or compression on fat, then what specifically causes these problems at the knee?  Conventional wisdom says adhesions form along the quadriceps that bind the IT band and prevent it from gliding freely.  However, actual evidence on the existence of these “adhesions” is sparse.  Spina (2007) discussed the use of Active Release Technique (ART) to break these supposed adhesions, but curiously provides no evidence of where and how the adhesions are located (though in this study therapy was applied to the hips as well for a case of snapping hips, and not isolated to the IT band).  Though manual therapy is proven work and should be a part of everyone’s IT band prevention and treatment regimen, few can honestly say WHY.  Understanding the reasons WHY can be the difference between being ready for the goal race and finding a resolution three weeks too late. 

The idea of tissue remodeling is open to sloppiness.  Yes, there are manual workers who promise their hands can “remove adhesions” just as coaches/trainers promise their propriety foam rolling techniques will cure one’s ills.  Both manual therapy and foam rolling have been shown to work, but not for the reasons many think.  When the reasons why something works don’t align with reality, it becomes harder to duplicate past success, and the athlete is often left searching aimlessly for answers.  When the reasons why something works are clear, it becomes easier to align interventions with need.

The IT band is made of Type III collagen, which is incredibly stiff.  Threlkeld (1992) found that remodeling of Type III collage requires 23-114kg of force…that’s a lot!  Manual work can effect positive changes along the IT band, but to suggest that permanent remodeling occurs is an unjustified leap of logic…is anyone delivering 23-114kg of force to the EXACT location where a supposed adhesion exists?  Doubtful. 

Tactile approaches can induce the body into a state where it can be trained to redistribute tension more efficiently, but we must be careful when explaining the exact mechanism.  Same applies to use of the foam roller.  We’re definitely not breaking adhesions in that case, but the foam roller nonetheless can elicit some type of positive adaptation, whether through proprioreception or eliciting a parasympathetic nervous reaction for an environment more amendable to healing. 

As for the knee pain, remember that inflammation doesn’t just “happen.”  The immune system controls the release of inflammation, but the immune system must answer to the nervous system.  Inflammation doesn’t occur unless the brain perceives a threat.  Resolving the physical damage is the first step, but not the only step.   Runners often assume that stiffness just “happens” but the characteristics of IT band sufferers are well documented. 

Among a group of female runners, Ferber (2010) found those with IT band syndrome had significantly greater peak rearfoot invertor moment, peak knee internal rotation angle, and peak hip adduction angle compared to controls.  Friedrickson (2000) and Finoff (2011) found significantly weaker hip abduction on injured runners than non-injured runners, although Grau (2008) found no link between the relationship between hip abduction:adduction ratio and injury. 

One theory behind the IT band: excess stiffness develops along the IT band as a subconscious strategy to compensate for instability in the hips and/or feet.   “Release” all the “adhesions” you like, but unless you provide an alternate source of stiffness, the brain has no reason to cooperate with your plans…expect the problem to return! 

Conclusion

In my observation, most runners have the right ideas to address IT band issues (manual therapy, stretching, strengthening) but are sloppy with the details of intervention.  Think of baking: you need a certain amount of ingredients and the ingredients must be prepared in an effective sequence.  Throwing everything into the pan and THEN adding cooking spray ain’t gonna cut it!  For IT band treatments, runners typically try a bunch of things randomly with the faint hope that something will work.  Given the ongoing prevalence of this condition, success rates are obviously poor.   Understanding what we know and don’t know about the condition can help guide interventions at all stages. There are many tools and techniques that work...focus on building a system within which they can thrive.  

Length/mobility --->Excess stiffness is often the proximal cause of painful triggers, but is also a strategy for stability.

Strength/stability ---> Give the tissue that you have mobilized a reason to stay mobilized!  Without strength to help unlearn inefficient stabilization strategies, you’re likely to revert back to painful habits. 

Timing/coordination ---> Learn non-provocative gait strategies.  Taping and footwear can aid the process but should not be relied upon as the sole interventions. 

Finally, judge all claims with a dose of skepticism.  Unless your medical provider is skilled at coaching (and is in a position to provide that service), the job is not complete without a referral to a coach who can help with strength and technique work.  Likewise, if the coach is unable to coordinate with the medical team, you probably need a new coach.  IT band is not for the faint of heart!  Have a plan, understand the WHY behind each intervention, and address all elements in a targeted sequence of measured doses.  

References

Muhle C, Ahn JM, Yeh L, Bergman GA, Boutin RD, Schweitzer M, Jacobson JA, Haghighi P, Trudell DJ, Resnick D.  Iliotibial band friction syndrome: MR imaging findings in 16 patients and MR arthrographic study of six cadaveric knees.  Radiology. 1999 Jul;212(1):103-10.

Strauss EJ, Kim S, Calcei JG, Park D.  Iliotibial band syndrome: evaluation and management.  J Am Acad Orthop Surg. 2011 Dec;19(12):728-36.

Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M.  Is iliotibial band syndrome really a friction syndrome?  J Sci Med Sport. 2007 Apr;10(2):74-6; discussion 77-8. Epub 2006 Sep 22.

Grau S, Krauss I, Maiwald C, Best R, Horstmann T.  Hip abductor weakness is not the cause for iliotibial band syndrome.  Int J Sports Med. 2008 Jul;29(7):579-83. Epub 2007 Nov 30.

Ferber R, Noehren B, Hamill J, Davis IS.  Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics.  J Orthop Sports Phys Ther. 2010 Feb;40(2):52-8.

Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA.  Hip abductor weakness in distance runners with iliotibial band syndrome.  Clin J Sport Med. 2000 Jul;10(3):169-75.

Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment.  Sports Med. 2005;35(5):451-9.

Finnoff JT, Hall MM, Kyle K, Krause DA, Lai J, Smith J.  Hip strength and knee pain in high school runners: a prospective study.  PM R. 2011 Sep;3(9):792-801. Epub 2011 Aug 6.

Spina AA.  External coxa saltans (snapping hip) treated with Active Release Techniques: a case report. J Can Chiropr Assoc. 2007 Mar;51(1):23-9.

Comments

G-Form Knee Pad

Thank you for this extremely brilliant blog! We really appreciate your blog post. There are actually a multitude of techniques we could put in to make really a good use of information without much efforts and financial resources. Thank you so much for giving light to many problems we haven’t come across before using your blog.

Threlkeld 1992 Article reference

Hello,

Awesome information! This is the kind of stuff we preach at our physical therapy clinic, great work. I was wondering if you could please provide the Threlkeld reference. Thanks, hope to hear back from you.

Roy Garza, PT, FAAOMPT

Threlkeld reference

Thanks for your comment, Roy.  Sorry for the delayed reply and for omitting the reference...had some technical issues on the back end of our site which hid some comments from view!

Threlkeld AJ.  The effects of manual therapy on connective tissue.  Phys Ther. 1992 Dec;72(12):893-902.

Even better than the reference...full text is available HERE

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