ITBS - is there any hope?

[Sports_Rx]

Hi, bear with me, I'm new hope I've posted this in the right section. I'm a sports therapist and I've been suffering with ITBS for 5/12 now.

It's not affecting my job but has stopped my running - if I said it was getting me down that would be an understatement I'm a recreational runner doing 20 miles p/w, longest run 6 miles. Now I can't run more than 2 miles without lateral knee tightness; beyond that I get pain which takes 3/7 to settle.

Can't be sure how it started, may have been overstriding or change in muscle mechanics. I weight train (free weight squats, lunges, deadlifts) and do core work etc. I am no spring chicken (nearly 40) so I accept collagen changes etc. Mass = 50kg. I have no L/Sp probs, very strong back from weights and I'm flexible in L/sp and hams.

Obers test -ve. I have tight external hip rotators on the affected side from how I used to sit as a child. I have no hip pain but there's tenderness around the greater trochanter on palpation. Lateral JLT, going down to fib head. Meniscal probs excluded. I have custom made orthotics in my runners as I overpronate. I am a forefoot runner also.

I've tried resting it completely with no exercise for 3/52 - no difference. Tried rest + stretches - piriformis and ITB - no difference. I added bodyweight one-legged squats in 3 planes, lying side leg lifts, VMO/Ad pillow squeezes & extensions, eccentric step downs frontal and lateral - did this for 3/52 on both legs.

Used a foam roller after any test 'runs' as there's trigger points along the band - - this helps with the tightness but the underlying problem is still there. Iced after test runs too.

Admitted defeat with self Rx and saw physio. He's treating me with acupuncture - needles from ankle, lateral lower leg, along the band, piriformis and L/sp. I've had 2 sessions - the first helped more than the second. Due to have another one today. Certainly feels different after a session. I've done a bit of self-massage for the trigger points, stripping up the band in the shower, and this helped a lot with the tight feeling. I've limited this since having the acupuncture though.

I still have lateral knee pain friction at around 30 degress - noticeable when I lie on my affected side in bed and bend my knee back and forth - only mild though, 2/10. I don't get knee pain on anything other than running, then all knee mvts are painful if I flare it up.

Obviously there's something I'm doing that's not allowing it to heal? I haven't run for a month (done very little activity in fact) since having treatment, to give the acupuncture a chance to do its stuff. Physio advised me to lay off the stretches and strength work.

Does anyone here have any suggestions for me? Thanks for reading this long post

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[physio.smith]

If you are able to run at min. then check out running and film on treadmill from sides, back and front.

Look at obviouse things first..
*foot positions, heel strike / toe off
*rotation of limb, below and above knee
*stride length
etc..

Also look at...
*belly button movt. (can give indication of compensation)
*arm, shoulder, neck / head position and fixing of
*lumbar spine, creases and movt. from centre

If not already looked out check - out route you run...camber, hill (lead leg)
- shoe wear pattern etc, your orthotics
- lumbar spine

Important to ensure able to dissociate lumbar from hamstring movt. (kinetic control work good for this and getting good control of firing pattern of gluts. etc)

Glut. med work...starting side lying, often those with tight ITB tend to over use TFL when doing this, make sure you are using what you are meant to....may need to look at high and low threshold activation and control (compare side to side), this can be progressed obviously to standing / dynamic ex. Kinetic control is again good for this

Don't forget to check neural structures, mobility of nerves etc..

Good luck.

[Sports_Rx]

Thanks for your reply physio.smith.

I've assessed how I run but not videoed it. I'm very upright and I think I need to lean forward more to make use of gravity and activate my hams in the toe-off phase. I don't have excessive hip sway or lateral upper body mvt and my neck and shoulders appear neutral.

Prior to injury I was doing the same mileage but running it faster, as I got fitter. I think this is when I may have over-strided. I'm aware of keeping my lead leg in line with COG now.

Although I overpronate on both feet, my R) foot (affected side) lands in a supinated fashion, so I guess this means more pronation mvt as it goes through to toe-off.

Shoe wear pattern is suprisingly even. I run on roads, tracks and trails, but alter position if on road to take account of cambers (quiet country roads thankfully).

Physio did unilateral PIVM on L5 and I felt a sensation in my hip on affected side, no pain, so there may be some spinal involvement.

Would I be better do standing side leg lifts then, as I do feel it in my TFL. Maybe free-standling ones? I have been doing some 1-legged balance stuff on my wobble disc too.

Appreciate any advice re kinetic control work for my glute / hams?

[physio.smith]

If you know your right overpronates more, whilst landing more supinated and you have no leg length descrepancy then most likely a control problem. Make sure if you have not already that you check hip quadrant for tightness / alterted hip congruency right to left. Obviously as you have identified upping the pace is the likely cause...if your control is lacking at all at the hip you will whip over into pronation quicker and overuse lateral structures, irritating ITB.

Control work
I would ensure that you can do sidelying leg lifts first. Clam position, 90 at hips and knees, feet together, lift upper knee. If can't do this without bringing TFL then try with pilow between knees to put glut. med. into inner range and try this. Obviously you do need to get through range control...but it may help you get started.

If you can't get control in side lying then when you try and gain control with weight going through the limb you will constantly compensate. It may take sometime to regain control...it may also be being hindered if there is some Lx involvement.

Gluts / hams can be done prone with end of plinth tilted down, or standing leaning over plinth...definitely get a friend to help identify if you are kicking in your gluts.

[Sports_Rx]

I find clams really difficult on my affected side but I will persevere. I do them against a wall to stop me cheating

Control work

Gluts / hams can be done prone with end of plinth tilted down, or standing leaning over plinth...definitely get a friend to help identify if you are kicking in your gluts.

These leg lifts - is knee straight (for hams + glutes) or bent to 90 to isolate glutes?

Thanks for your time.

[physio.smith]

If you find clams difficult then pillow may well help, so don't have to go through whole ROM, you can just work on small movements. Think recommended was 10x10sec holds to work low threshold, need to work this area to prevent fatiguing when going on long run. Try not to use wall as this may lead to compensations, I had the same problem and found using a partner really help to get technique right in first place and monitor I was not cheating as I progressed through the exercises.

Gluts / hams...can start with knee flexed to isolate gluts more but aim is to initiate gluts then hams and in functional way...thus do need to do with straight leg at some point. (also make sure not activating lumbar muscles)

Nice exercise to try to see if you can dissociate lumbar from hams....
Sit on edge of plinth (feet flat on floor), use hands in small of back, tilt back and forth to find neutral, (make sure sitting tall) try and straighten your leg slowly and monitor what happens in lumbar area....tendancy is to slump if unable to dissociate.

Good luck, let me know how you get on.

Kinetic Control Courses really good for this sort of control work.

[Sports_Rx]

Just an update on my ITBS. It's still there I have trigger points in lateral hip and randomly down lateral thigh that flare up if I run (still only able to run 2 miles) or do any weight training (squats / lunges). Involved R) leg just feels heavy and tight all the time.

Still doing the glute med strength work - clams and wall presses with bent leg. Stopped the 1-legged squats as legs are strong enough. Still doing VMO work and stretching piriformis and itb. Foam rollering after running.

I've stiff L5 so have been doing prone extensions with pelvis fixed and also standing glide/ extension with PA pressure on L5. Physio recently diagnosed posterior torsion at my SIJ. Rx with MET technique and did unilateral PIVM on R) L5 as that facet joint is stiff.

What on earth next?!

[physiobob]

Hi there Sports_Rx, ITBS (iliotibial band friction syndrome) is exactly that, degeration caused by friction.

Step 1: Analyse the biomechanics of anything you are doing that may cause this. Make sure you look at your foot/ankle motion during running.

Step 2: Analyze the training regimen that could cause this with normal mechanics, not necessarily altered.

Then consider that this problems take a long time to product pain as a symptom. Therefore they can take months to heal once the other factors have been addressed. Treatments like acupuncture might assist with pain reduction and even tissue normalisation.

Think about where in the range of movement you are feeling the pain. This will give an indication as to what it is that you are doing to cause it, e.g. a deep squat is different to riding a bike that is again different to running. Which is worse?

Perhaps the biggest consideration is the inner thigh (adductor muscles) that must balance the overactivity of the gluteals in squatting movements etc. I rarely find someone with strong inner thighs or adductors that connect in a single leg support phase. You can work glut medius till the cows come home but without a strong connected adductor complex you are going to struggle to remain symptom free.

Remember the mechanics of swing phase of the leg: hip flexion, external rotation and abduction and that this movement mush be balanced by range and stablility to permit extension, adduction and internation rotation (relative) during stance phase. Often a lack of the later can cause a short stride and overactive gluteals.

So get videoing, restore function mechanics and give it time as pain is a good guide to whether it's all working.... or not

[sarah001]

Hi there, I'm not a physio but have trouble with my own IT bands and I just wanted to mention that during the clamshells I found the best way to ensure the glute medius works is to think about pulling the hip into the socket as you lift the leg, initially I found I actually had to pull the hip into the socket then lift the leg, but progressed to just having to think about doing it which cues the glute medius up before you start. Hope that helps.

[Sports_Rx]

Interesting physiobob, as I've always thought my problems were mechanical-based. I don't get any knee pain during squats etc, only the lateral leg tightness the day after. It's only running where I can bring on the pain. Can walk 6 miles pain-free too.

Sometimes when I'm running I can alter how my knee feels by controlling the swing phase of the lead leg. My physio recommended I look where the knee's going, and because I've a tendency to land supinated on that side, I do think the affected leg is externally rotating excessively.

This would link in with your comments about the need to do more adductor work to offset this. Reckon I'll have to do some pillow squeezes every day and add some wide leg squats to my rehab routine. Any other add work greatfully received

Finally, on my last 2 runs I've not run in my orthotics but some new support shoes (New Balance 858s). As I felt the orthotics were contributing more to my supination on my R) foot by having such a built-up medial section to control over-pronation. Felt like I was being over-corrected if you know what I mean? Only time will tell whether this is the right decision. It would be nice to get beyond 2 miles to test it out!

[aninditakharoo]

hi, i have a similar problem since couple of months, infact currently i m on physio for my knees and hamstring...the docs diagnosed VMO weakness and ITB tightness due to which i have severe pain in my knees (outsides and in the centre) while i climb the staris or be in sitting posture for long and so on (my knees kinda get locked and cant be moved further down)...i can absolutely not do lunges and squats is also not possible with weights...!! i have been taking "jointac" a painkiller / anti-inflammatory med for 3 weeks, not too sure if it has helped...but the stretching / electric treatment on knees indeed has.
My query is: the docs think it cud be due to lack of exercising, but i m active with my gymming and have been pretty much doing my regular lunges, squats, leg press etc with good amounts of pounds...!! the knee pain had surfaced bout 10 yrs back, but nothing was then found in x-ray...it has now suddenly cropped up and giving me trouble. Also when i do enough stretchings i m comparatively fine, but if i skip it for 2 days or so, it gives me trouble the next day...i do not wish to continue like this for sure...kindly suggest!!

Cheers!!
AK