ITB Friction Syndrome

[21st century Physio]

Hey all. Recently had a patient complaining of lateral knee pain particularly during running (especially downhill). Through various tests I narrowed the problem down the ITB. This is not a pathology I have treated alot.

Treatment wise:

I have decreased the inflammation using ice, NSAIDs and electrotherapy. I have used massage therapy to correct tightness in ITB, TFL and hip abductors. Given the patient ITB stretches and stretches for gluts and TFL. Hip abductor strength is 5/5.

After 3 weeks of progressive treatment the pain still exists with running.

Any hints on what is wrong with the treatment implemented or other factors that may be responsible for the pain?

Cheers

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• ITB Pain - what have I missed?

[ramleo]

Hi there,

ITBAND SYNDROME is:

Excessive friction between your Iliotibial Band and your knee (or hip) bone.
This causes a sharp pain at either the side of your knee or the side of your hip.

Usually caused by increasing your running or biking too fast and/or with bad form.

But is also associated with weight-lifting (standing squats), court sports (raquetball, tennis, handball, etc) and even pregnancy.

The most common causes :

Leg length differences
Road camber - running on a slope for a long time
Foot structure
Excessive shoe breakdown - particularly it the outside of the heel
Training intensity errors - increasing mileage or intensity too fast
Muscle imbalances - particularly quads versus hamstrings
Run/gait style factors - e.g. bow-leggedness, knock knees, etc.


Treatment:

Immediately

STOP RUNNING to prevent further inflammation, don't just ease off

RICE (Rest, Ice, Compression, Elevation). Ice - 20 minutes on, 10 minutes off, 3 times a session, twice daily. Be careful not to freeze the skin, especially if you use commercial ice packs, some of which freeze at a lower temperature than water.

Anti-inflammatory drugs (ibuprofen, you may find natural products such as Glucosamine and Condroitin Sulfate work for you),

Stretch ITB at least twice a day, 30-60 seconds each side, using at least 2 different stretches. Don't bounce, don't stretch till it hurts (i.e. too hard).

Self-massage of area, across the thighs and calves (sideways, not up and down).

I hope that it was of some help. Some more on ITBS next time.
Cheers

[spud1976]

hi
you might want to look at post glut med and glut max and psoas, strengths .possible instability at the hip jt
cheers

[physio237]

As a competative runner and physio student I have good understanding of this condition. I suffered with it on and off for years myself and physios rarely helped. Of all the various treatments, what worked for me was;

transverse frictions just proximal to the painful area.
Full sports massage to ant/post thigh and deep massage, including trigger points using elbows to gluteals (particularly glut med and piriformis)
IT stretches
Strengthening of glut med and quadratus lumborum (hip hitching)
Stengthening of quads to prevent pallellar medial deviation on affected leg.
Stregthening of leg to provide stability for excessive mobility in subtalar joint
Orthotic devices to correct leg length discrepancy, and fallen arch.

never running on a cambered road and alternate the direction you run a loop
increase milage very slowly
ice if painful

[soranidinesh]

hi
i read ur case and found interesting. i think u should try for lateral patellar glide and tapping. additionally you can try lateral patellar mobilization with knee movement as per mulligan concept. i think it can be the problem in the patellar band of ITB which is giving pain.
u can try once and rule out if that is the thing.
dinesh

[neurospast]

When I read your treatment,physio237, something creeps up my mind; friction>pain, massage gluts> hyper tone and instability of foot. one connection can be made: The lumbar spine! It has not been mentioned in this case so your problem will continue. I refer as well to the original question, though.
You have to establish if there is a neurological conection between the different symptoms; Glutei (Both Hypertone) and Tensor facia Lata. Mechanical effect of hypermobile joints in the foot on the back (and the knee).

[sdkashif]

Iliotibial band (ITB) syndrome (ITBS) is the most common cause of lateral knee pain among athletes. ITBS develops as a result of inflammation of the bursa surrounding the ITB. It usually affects athletes who are involved in sports that require continuous running or repetitive knee flexion and extension. This condition is, therefore, most common in long-distance runners and cyclists. ITBS also may be observed in athletes participating in volleyball, tennis, soccer, skiing, weight lifting, and aerobics.

The ITB is a wide flat structure that originates at the iliac crest and inserts at the Gerdy tubercle on the lateral aspect of the proximal tibia. The band serves as a ligament between the lateral femoral condyle and the lateral tibia, stabilizing the knee. The ITB assists in 4 movements of the lower extremity.

Abducts the hip .

Contributes to internal rotation of the hip when the hip is flexed to 30° .

Assists with knee extension when the knee is in less than 30° of flexion.

Assists with knee flexion when the knee is in greater than 30° of flexion .

Aetiology:

There are many factors that are considered to be responsible for the development of iliotibial band syndrome.

Training errors:

In runners the posterior edge of the ITB impinges against the lateral epicondyle of the femur just after foot strike in the gait cycle. This friction occurs at or slightly below 30° of knee flexion. Downhill running and running at slower speeds may exacerbate ITBS as the knee tends to be less flexed at foot strike. Running on hard surfaces and banked surfaces: The injured leg often is the downside leg on a banked or crowned road. Worn out or improper running shoes. Lower limb and foot misalignment - Valgus or varus alignment of the leg or leg-length discrepancy .

In cyclists the ITB is pulled anteriorly on the pedaling downstroke and posteriorly on the upstroke. The ITB is predisposed to friction, irritation, and microtrauma during this repetitive movement because its posterior fibers adhere closely to the lateral femoral epicondyle. Cyclists with external tibia rotation greater than 20°: Stress is created on the ITB if the athlete's cycling shoe is placed in a straight-ahead position or the toe in a cleat position. Cyclists with varus knee alignment or active pronation place a greater stretch on the distal ITB when riding with internally rotated cleats. Poorly fitted bicycle saddle: A high riding saddle causes the cyclist to extend the knee more than 150°. This exaggerated knee extension causes the distal ITB to abrade across the lateral femoral condyle. Bicycle saddles that are positioned too far back cause the cyclist to reach for the pedal with a resultant stretch to the ITB.

All athletes the other training errors are Improper warm-up and stretching, Increasing the quality and quantity of training sessions too quickly, Lower limb and foot misalignment - Valgus, or varus alignment of the leg, or leg-length discrepancy, Worn out or improper athletic shoes, On occasion, a contusion to the knee may precipitate ITBS.

Limb Length discrepancy:

Limb length inequalities cause changes in hip abduction during the gait cycle, sacral leveling, and pelvic tilt, which is believed to increase tension on the ITB and tensor fascia lata.

Genu Varum:

Genu varum is considered a risk factor due to the increased tension on the ITB as it is stretched more over the lateral femoral epicondyle.

Over Pronation:

Overpronation is controversial as well. In the running cycle, the lower limb strikes the ground with a rigid supinated foot. As the leg moves forward, the tibia internally rotates over the planted foot, "unlocking" it into a pronated-everted position, which allows for weightbearing. Pronation and internal rotation stress the ITB. Excessive pronation causes quicker tibial internal rotation and increased hip adduction, stressing the ITB over the lateral femoral condyle.

Weakness of Muscle Groups:

Weakness of muscle groups in the kinetic chain may also result in the development of ITBS. Weakness in the hip abductor muscles such as the gluteus medius may result in higher forces on the ITB and the tensor fascia lata. When the foot strikes the ground, the femur adducts against the eccentric load of the abductors (gluteus medius and tensor fascia lata). These muscles move from eccentric to concentric through the support phase and into the propulsive phase of gait. The gluteus medius also externally rotates the hip, while the tensor fascia lata internally rotates.

When the hip abductors are weakened or fatigued, runners have increased adduction and internal rotation at midstance. This generates more valgus force at the knee.

Myofascial Restriction and inflexibility:

Myofascial restrictions and inflexibility can increase stress in the posterior ITB, particularly with the tensor fascia lata. Tightness in the hip flexors (iliopsoas), extensors (gluteal muscles), and rotators (particularly piriformis) can shift more load to the abductors and adductors. Weaker hip abductors eventually fail under continuous stress.

Management:

A suitable management plan could be followed as under:

Acute Phase:

Local ice massage: Apply to the region of inflammation near lateral femoral condyle for no longer than 15 minutes. Ice compresses or cold packs can be used for 20 minutes.

Phonophoresis and/or iontophoresis: Use hydrocortisone or a similar topical steroid preparation with ultrasound (phonophoresis) or electrical stimulation (iontophoresis) for control of inflammation.

Activity modification: Examine recent changes in training, such as duration and intensity of exercise. Curtail activity to a level at which pain is not generated.

Often cyclists diagnosed with ITBS have their cleats positioned in internal rotation. This position increases tension on the ITB. To eliminate stress on the ITB, the cleats should be adjusted to reflect the cyclist's anatomic alignment or they can be rotated externally to reduce stretch on the ITB. If the cyclist is riding with fixed clipless pedals, a switch to floating pedals often is beneficial.

Evaluate the cyclist’s saddle or seat position. A saddle that is too high should be adjusted so that 30-35° of flexion is present at the bottom of the pedaling stroke. Consider reducing stress on the ITB by widening the cyclist’s bike stance and by improving both the hip and foot alignment. This correction can be accomplished by placing spacers between the pedal and the crank arm.

In runners Inspect running shoes for uneven or excessive wear.

Evaluate and identify anatomical factors, which may contribute to ITBS. If a leg-length discrepancy is present, consider prescription of a heel lift. Many runners have a tendency toward foot pronation or supination. If either is present, orthotic devices may be helpful.
Runners should modify their training modification to avoid running on banked surfaces.

Sub Acute Phase:

Stretching exercises: Begin after inflammation subsides. Restoring proper range of motion in the hip flexors (iliopsoas and quadriceps), hip extensors (gluteus maximus, hamstrings), hip abductors (gluteus medius, tensor fascia lata), and, most importantly, the hip adductors is crucial to restoring overall hip function.

Myofascial therapy: Direct treatment on trigger points and loosen restrictions along the ITB. Target areas include over the lateral femoral condyle and greater trochanter. The techniques used are stretch and spray therapy, ischemic compression, massage, myofascial release techniques. PNF techniques of like Hold- relax, Contract- Relax may be used to achieve the lengthening reactions in the muscles.

Manipulative therapy: Effective in treating areas of restriction and repairing the biomechanical flaws that led to the ITBFS. Muscle energy techniques can be safely applied to the tensor fascia lata, hip flexors, and piriformis muscles to restore ranges of motion in hip adduction, extension, and internal rotation. Attention should be paid to lumbosacroiliac mechanics to ensure resolution of any dysfunction there. Anterior or posterior rotational innominate (iliac) dysfunctions affect the origin of the tensor fascia lata and can delay recovery if left untreated. Other specific areas to address with manipulation include the T12-L1 vertebral segments (origin of the iliopsoas) and the fibular head (partial insertion point of the ITB). In fact, fibular head dysfunction (either anterior or posterior rotation) cannot only contribute to ITBFS but can mimic it as well.

Recovery Phase:

Progressive strengthening exercises are started to restore muscle strength lost from inhibition and disuse. Exercises include side-lying leg lifts, pelvic drops, and step-down exercises. The patient should be instructed in a home exercise program that continues to improve the strength and endurance of the hip and knee, as well as the back and abdominals. Strengthening of the hip abductors and knee flexors and extensors is an important.

Maintenance Phase:

Integrate active ITB stretching and strengthening of the hip musculature into the training programme.

[eugaa3]

You say your patient ahs 5/5 strength of hip abductors but how have you tested this? Someone can have what seems a good isometric test result but you look at repititions or holding and you begin to identify weaknesses. And you need to look at hip abductors, external rotators and extensors. BUT is it actually weakness or inhibition? Never forget the lumbar spine as it is frequently the reason gluts perform poorly. Not forgetting foot overpronation, hip range etc etc. There is always alot to look at biomechanically in such patients. Probably the main thing though is has the patient been advised to relatively rest??

Angel

[arunja]

I would like to comment some tips about the lateral knee pain. I think we can think some more laterally. Better once check the Tibio Fibular joint. This joint is neglected or ignored in most of our clinical diagnosis. Because as you said there is pain in running , we should check for the TF movmnts. There is cephalad and caudal movmnts taking place in this joint while we walk or run . Or else we can say that , it acts as a shock absorber in our body, moving up & down. If you can mobilise the joint in Anterior posterior direction and also by sup & inf mobilisation by ankle plantar and dorsi flexion will be good,

In IT band what was the result of Obers test, because the pain is in activities we should think about the closed kinematic movmnt which cause the reverse pull ..

[physiobob]

You guys might also check out another thread in this forum on ITB at /forum/showthread.php?t=636

I would suggest that already most of the immediate considerations have already been discussed. How to put them together into what is wrong, what was the primary issue and what is the best rehab now is the challenge