Resolving Iliotibial Band Syndrome (Lateral Knee Pain)

Iliotibial Band Syndrome (ITBS) is an overuse injury seen in runners, cyclists, soccer players, skiers, and weightlifters. ITBS is one of the most common causes of lateral knee pain. This condition often never completely resolves with conventional treatments, since most practitioners do not typically address all of the key structures involved in this injury.

Traditional Perspectives

Traditionally ITBS is seen as a friction syndrome in which the iliotibial band rubs against the lower portion of the leg (lateral femoral epicondyle of the femur). It has been postulated that this occurs when the iliotibial band moves anterior and posterior during knee flexion and extension. This repetitive motion causes friction, micro-tears, and inflammation of the area. (including a bursa located between the lateral epicondyle and the IT band).

Numerous researchers have demonstrated that the most intense pain is experience at about 30 degrees of knee flexion (a zone of impingement). This is certainly the perspective I was taught during my orthopedic classes 25 years ago. It is also the logic that most practitioners use to formulate a treatment strategy. The only problem is that this perspective is WRONG….

What the Research is Telling Us

With recent research, this traditional perspective has definitely come into question. This is primarily due to the discovery of anatomical factors that actually prevent the iliotibial band from moving in an anterior-posterior direction.  Research has demonstrated that the iliotibial band is actually firmly anchored to the leg (linea aspera of the femur) by a sheet of strong connective tissue (intermuscular septum). In addition it is also attached by strong fibrous strands just above the knee (lateral epicondyle) and deep into the bone.  These strong attachments prevent the iliotibial band from sliding anterior and posteriorly over the lower leg (lateral epicondyle) as was previously assumed.

Anatomy and Function of the ITB

Anatomically, the iliotibial band (ITB) is a thickening of a structure known as the fascia lata. The fascia lata is a web of connective tissue (fascia) that completely covers your entire leg. Think of the fascia lata as a sock encasing your entire thigh. The iliotibial band (the fascial thickening) is located on the lateral aspect of your thighand is not an independent structure; it is a fully integrated part of the fascia lata. Which makes the postulated anterior-posterior motion pretty much impossible since it cannot glide independently.

The Iliotibial band is also part of a structure called the “Pelvic Deltoid Complex”.  
In this complex, the superficial layers of the gluteus maximus muscle from the posterior hip and the fibers from tensor fascia lata muscle at the front of the hip fuse into the Iliotibial band.  These muscles collaborate with each other to raise the hip to the side (abduct the hip).  They also assist the gluteus medius muscle (an abductor) in maintaining the pelvis in a neutral position when standing on one leg (Stance Phase of Gait).

In addition the IT band acts as a brace that decreases bending stresses on the leg (femur). It does this by converting tensile loading to compressive loading on the lateral aspect of the leg.

Look at Hip Strength! Not IT Band Length

When the muscles of the hip become weak, there is an increase in the inward motion (adduction) of the leg.  This becomes evident during the Stance Phase of Gait.  This inward motion increases the amount of force directed through the iliotibial band, which in turn causes compression of the tissue of the lateral knee.

This is exactly what researchers have found in individuals who suffer from ITBS.  ITBS sufferers have weak gluteal muscles (abductors) and an increase in inward motion (adduction) of the hip during the Stance Phase of Gait.

The Problem Lies in the Fat Pad, Not in the Bursa

Earlier, we mentioned that the conventional perspective believed compression of the bursa is the cause of the pain. (A bursa is a fluid filled sac found between anatomical structures). Unfortunately MRI studies have shown that there is no bursa between the IT band and the lateral knee.  From a biomechanical perspective, there are no bursa in this area because there is no need for one.  Without the presumed anterior-posterior motion, there is no need for reduced friction.

However is in the area between the IT band and lateral knee (the site of pain), there is a layer of highly innervated fat, a layer of fat full of neurological receptors. Compression of this area is the most likely cause of the lateral knee pain in Iliotibial Band Syndrome.

Treatment of ITBS

This new information has completely changed our approach for treating ITBS. Using this new approach we have obtained excellent results in even the most stubborn cases.  If you would more information, or to book an appointment to have this condition (or another musculoskeletal condition) treated, just give us a call. 403-241-3772.

Iliotibial Band Syndrome (ITBS) - Part 4

Treatment of Iliotibial Band Syndrome

The first thing practitioners must do in treating Iliotibial Band Syndrome (ITBS) is to perform a biomechanical analysis. In this process they evaluate the patients gait for alteration in movement patterns. This will give them an initial hypothesis as to which structures are involved. Refer to Parts 2 and 3 of this Blog to see what muscles are involved in what actions.

Then the practitioner will need to examine these areas (hands-on palpation) to confirm that there is a restriction present. The practitioner will feel an alteration in normal tissue consistency, it will feel ropy, rigid, and there will be a lack of tissue glide between adjacent structures. Once the area to be treated has been identified, manual therapy can begin. There are several forms of therapy that can achieve good results in addressing myofascial adhesions (Active Release, Graston Technique, Massage Therapy, and Fascial Manipulation).

Fascia and ITB Syndrome

When we evaluate a case of ITBS, we must also take into consideration all the fascial connections to the structures that are involved in performing and coordinating ankle, knee, and hip motion.

In the case of ITBS, some of the fascial connections we should consider are in the Lateral Line (see Anatomy Trains by Thomas Meyers).

The following is a short synopsis of the lateral line. I have also included a link to the Anatomy Trains dissection video about the Lateral Line – Thomas Meyers Lateral line Video.

Lateral Line

· Beginning at the foot with the peroneal muscles, fascial interconnections travel up the outer leg to just below the knee (fibular head). This fascia then connects directly into the lower IT band into the deltoid complex (gluteus maximus, gluteus medius, and tensor fascia latae).

· The fascia then connects to the pelvis (iliac crest), which connects into the abdominal muscles (internal and external obliques), and then into the quadratus lumborum which connects into the ribs and the spine.

· The fascia then travels up between the ribs (intercostals muscles) and continues up the body to connect into the fascia of the neck (SCM, splenicus cervicis, and scalenes).

Once you see these videos, you will find it very hard to dispute the importance of these fascial connections.

Bottom Line: You can try treating ITBS with all the right techniques (ART, Graston, Massage etc.) and find that you still have not resolved a chronic ITBS problem if you do not consider, and treat, the fascial interconnections.

The key is to any therapy is to address all the structures involved in the kinetic chain.

Treatments need to be specific and based upon the individual requirements of each person. Treatment should not be a cookbook approach. Practitioners need to find the specific tissues that are restricted and physically work them back to their normal consistency.

Exercise is Essential

Often getting professional help in the way of manual therapy is essential to get a complete resolution of ITBS, but just as important is exercise. Without the right exercise program the probability of this condition returning is very high.

There are three important areas which must be addressed when prescribing exercise routines for ITBS, strength, flexibility, and balance.

Why strengthening exercises are essential:

Every time you injure yourself, your body lays down new tissue to repair itself. The new tissue is initially very fragile, thin, and easily torn or re-injured. Strength or weight training places stress upon these new tissues, causing them to go through a process of remodeling. In this process, the new tissue literally converts from one type of collagen to a different type which is up to 10 times thicker and 10 times stronger. However, this collagen conversion only occurs when you apply continued stress upon the tissue as you do in weight- and strength–training exercises.

Exercise example: Because the iliotibial band is formed from the deltoid complex, having strong balanced hips is essential for a full resolution of ITBS. One of my favorite exercises to increase hip strength is the Bulgarian Split Squat.

Why Flexibility exercises are essential:

During the regenerative or repair phase of an injury, your body creates and lays down collagen to repair the injured area. When the injured person performs the correct stretching exercises, the majority of new tissue will be laid down in the same direction as the tissue that is being repaired - thereby allowing this tissue to properly perform its function.

Exercise example: We suggest that patients combine stretching with self myofascial release (foam rollers). The following is an example of an ITB stretch, and a foam roller video you will find very useful.

Why balance exercises are essential:

Proprioceptive or balance training is a fundamental requirement that should not be ignored in Rehabilitation Therapy. Your ability to balance depends on feedback from your auditory, visual, proprioceptive (sense of body position), and vestibular systems (relating to the sense of equilibrium). All of these systems must be trained to achieve optimal results. As with all injuries your nervous system is often affected. Training these systems, ensures a greater chance of a complete recovery.

Exercise example: The follow exercise is an example of the type of exercises that we prescribe to our patients. This is the Squat - Single leg balance exercise from Core Performance.

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Iliotibial Band Syndrome (ITBS) - Part 3

Hip Muscles Directly Affect Knee Function

Actions of the hip directly affect knee function; in fact, if these relationships are not considered, the practitioner will have little hope of resolving a great percentage of chronic knee problems such as Iliotibial band syndrome.

Muscles involved in hip flexion:

· Adductor Longus and brevis

· Gluteus minimus and medius (front section)

· Psoas and Iliacus Tightness in the psoas muscle often occurs from hyperextension of the low back (lumbar spine).

· Rectus femoris (Quadricep)

o This is the only quadriceps muscle that crosses both the hip and knee joint.

· Tensor fasciae latae

Muscles involved in hip extension:

· Adductor Magnus

· Hamstrings (Biceps femoris (long head), Semimembranosis, Semitendinosis

· Gluteus Maximus, Gluteus medius (posterior section)

Muscles involved in hip abduction:

· Gemellii

· Gluteus minimus and medius

· Obturators

· Pelvic Deltoid muscle –

· The tensor fasciae latae and gluteus maximus (superficial layers) insert into the Iliotibital band. These muscles work in concert to abduct the hip. If you have a problem with any of these muscles it will affect ITB function.

· Piriformis

· Sartorius

Muscles involved in hip adduction:

· Adductors (brevis, longus, magnus)

· Bicep femoris (long head of this hamstring muscle)

· Gluteus Maximus

· Gracilis

· Iliacus

· Pectineus

· Psoas

Muscles involved in internal hip rotation:

· Gluteus Medius/Minimus

· Tensor Fascia Latae

Muscles involved in external hip rotation:

· Gemelli and Obturator muscles

· Besides their rotational function these muscles help to decompress the hip joint. Some authors refer to this as a hammock effect.

· Gluteus Maximus

· Piriformis

· Quadratus Femoris

In part four of Resolving ITBS, we will cover treatment and exercise.

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)