What am I missing ? (recurring ITBFS)

[Bikerphys]

Someone please help !!

I've a patient, male competitive cyclist, presented 12 months ago with classic ITBFS symptoms, (R knee) treated succesfully with SSTM, assisted stretching to ITB/TFL and Glutes, u/s and laser, regular strectching protocol advised ... end of problem.

BUT Jan this year, pt went skiing, day after return went for a 100+ mile bike ride (pushing it !), came to me day later c/o similar symptoms to initial ITB problem.

full assessment revealed tight ++ (R) TFL/Gluts/ITB, Hams and Quads.
no ligament/meniscus damage, no instability,locking, etc.
this time however, his right plantar arch has dropped with medial tibial rotn resulting.

treatment so far has been RICE, and a combination of SSTM, stretching, u/s, laser and recommendation to use orthotics to correct the biomechanical insufficiency.

But it's not responding and I'm running out of ideas, beginning to wonder about my effectiveness and getting very frustrated (as is my pt)

please can anyone offer any advice, am I overlooking something here ?

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[Physiobase]

Br radical as this person seems to revel in abusing their body.

Put the seat up a full inch and get them to ride 100K, then put the seat down 1" from where it is now and get them to ride 100k. The will find areas of the legs that start to pain, cramp, blow out etc. This will perhaps highlight less than obvious weaknesses that have in other areas that need strengthening.

Strengthen those and then see if their mechanics change and the ITB pain reduces. Medial hamstrings and adductors come to mind.

p.s. I realise this is a bit left of field but it worked for me with some rotation issues last year and felt quite hard core.

[alophysio]

Sorry if this is a redundant question...

Does full assessment mean you checked the L/S and SIJ as well?

I was only thinking that because you don't mention how far up you went and skiing is pretty intense on the old pelvis you know...:lol

The other question I had was: Are the muscles actually tight or overactive?

Thanks

[Bikerphys]

Thanks for the comments,

I assessed SIJ and L/S, all to note was slightly stiff end feel to R uni p/a L4/5 (springy but restricted rom)
SIJ clear, leg length L=R
Muscle strength L=R all lower limb
erector spinae L=R
Quad Lumb/ Iliopsoas L=R

pt had 'sciatica' c radiating symptoms to mid post thigh ~ 4 y ago, rx by GP was facet joint steroid inj. (pt. not sure where exactly, ? L4/5) produced relief; no further symptoms.

approx 2 months prior to this complaint, pt changed his pedals (same manufacturer, different model - Time c 15 deg of float)

he is a professional bike mechanic and is pretty sure his set up is correct. I suggested the saddle height +/-, but he's not too keen on that idea !

Spends most of his working day standing working on bikes, even the workstands are raised on blocks to maintain good posture !
doesn't do any other sport, non smoker, non drinker, no previous injuries of note, no other medical problems.


re. muscle tightness/overactivity, forgive my ignorance , but not sure how to determine this, please can you explain ?


thanks again for advice, any further pearls of wisdom much appreciated.

[alophysio]

Hi.

No stress about the overactivity thing

For me, something is overactive when it is inappropriately activated - if that makes sense... For instance, during relaxed standing, your should not have your obliques switched on since they are a phasic muscle and relaxed standing (not doing anything) is a tonic muscle activity.

Another example is when your patient is lying prone and their hams are obviously not relaxed and you have to keep reminding them to "let go" of their muscles or "relax" and then they switch them off for a short period of time but they gradually come back on again.

For me, their "normal" pattern of muscle activation is stuffed.

In contrast, a tight muscle is where the physical length of the muscle is decreased at rest. This can be seen well in women who wear high heeled shoes for most of their life - short soleus muscles.

A simple example for seeing an obvious difference in a test would be a passive SLR. Get the patient (or a friend) to active their hams and then do a SLR. Vary the amount they switch their hams on and you will get a varying amount of ROM. Ask them to completely relax and re do the test. You should get further.

A simple rule is that phasic muscles should only be really used during phasic activity. If you are trying to teach someone how to switch on their "core" in supine or crook-lying (supine with knees bent), you have to watch for the activation of the obliques and rectus abdominus. But if you were getting them to do a roll-up from supine with a twist, then you are concentrating more on having the sequence of core before phasics because movement of the trunk will require the obliques.

In the case of this biker, are his deep posterior hip rotators tight or overactive? Are his muscles balanced?

Hope that helps - and that I got it right! Please correct me if I didn't explain it properly...:lol

[physiosmith]

I know he's a bike mechanic, but have you tried videoing him while he's riding? It can be very revealing, and people who think they have an ideal set up could be shifting in their saddle, too far forward or back in the saddle, be extending too much at the knee or ankle, or indeed be too low on the saddle requiring other compensations.

Cyclists also like to keep the knees tucked in to reduce drag, but should ideally have the knees driving down over the pedals - if he is internally rotating it will have a direct impact on the knee and thus the ITB.

Get him to bring in a roller and video him from the back and side, he might be surprised.

[robbo911]

I agree with using the rollers and a video camera. It works extremely well if you have slow motion.

Has this cyclist changed their training load (ie hill repeats, distance etc), saddle position (fore/aft, up/down)?

Also with the cleats does the client have them turned to match their natural toe in/out? Cleats don't have to point straight forward as is a misconception.

Are they wearing their orthotics when riding? If so did they change their saddle height and fore/aft position to suit the added thickness of orthotic?

As for the medial rotaiton check for tibial torsion, tight medial Hamstrings, hip flexors or weak gluteals.

Also check saddle position. Some people put the nose of the saddle down. This will cause an anterior rotation of the pelvis and can exacerbate a medial knee position thru not activating gluteal muscles correctly.

good luck

[timphysio]

As the last 2 replies stated, the last cyclist I saw with problems like this responded very well to checking/altering his cleats/foot position to reduce tibial rotation internally, and had poor Gluteal control of femoral rotation which did improve with kinetic control exercises.

[jerryhesch]

iN ADDITION TO PREVIOUS POSTS (oops sorry re caps) test all accessory motions in the pelvis up to T-12 and hip knee foot and ankle and restore those that are restricted. Be thorough such as Hesch Method protocol and only then evaluate for orthotics. Onc cannot adequately stretch soft tissue if it is reflexively responding to another "input" and the same is true if there is a significant biomechanical restriction i.e. posterior ilium, Type 1 or Type 2 inflare/outflare of pelvis, etc.
jerry hesch

[spud1976]

my 2 cents

cycling is alot of hip flexion, his ITB/TFL might be over dominatant and flexing his hip and causing knee pain have you checked his inner range psoas ( seated ant tilt and passive hip flexion then get patient to actively hold while you resist to nuetral) if psoas is weak then he might be getting a hip impingement problem. You also might have to corect his movement pattern if its faulty, you can strengthen all you want but if he isn't using the correct pattern then impaiment can set in.

I would recommend having a read of Shirley Sahrmanns' book on hip impingement. please tell us how your patient gets on

cheers

[Bikerphys]

Dear all,

thanks again for the contributions, very helpful and reassuring.

My pt has had 2 weeks off the bike now, basically resting up and allowing any ongoing inflammation/micro trauma to settle.

He's continued with a general stretching regime addressing all lower limb and spine muscles.

Assessed him yesterday and although symptoms have settled and pain is reduced, he still has a focal area of tenderness generally between distal insertion of biceps femoris and posterior distal fibres of ITB. no swelling apparent.

there is an area of fibrous thickening and any attempts to probe beyond superficial layers results in fasciculation of biceps fem.... no trigger points found.

Alophysio, thanks for your valued input, and yes I would say his hams are definitely overactive, He really struggles to relax with assisted stretching and seems 'hypersensitive' almost during palpation of lateral hams and ITB, almost produces a reflex withdrawal response at times !

As for videoing him, yes, done that and his action (before orthotics) was a pronounced 'knee in' in flexion with resulting increase tibial internal rotn. the orthotics have corrected this and his knee and ankle now describe a linear plane of motion.

Not sure about his glutes, muscle strength is good but hes got the smallest 'buns' I've ever seen !!:lol

my plan is: release adhesions around lateral structures, restore length with sstm/stretches, introduce specific glutes strength exercises.

anything else I ought to consider !

thanks for all your comments and advice, I think I'd got to the stage where I couldn't see the wood for the trees 8o

regards

[Physiobase]

Sounds like what is now becoming evident is the overactive lateral hamstring with resultant posterior lateral knee joint compression. Remember that area is tender to palpate in a normal subject. It all sound familiar to my body when my quads were to weak! My suggestion of increased seat height for a few rides, and then lowering for a few rides is no joke, it does let the body feel where the weak areas are and you can almost feel their weakness leading to the resultant change in recruitment and maybe even pain/discomfort. Even moving the seat back an inch will put pressure back to the quads and tell him not to pull up to much on that leg by "scrappinh the heal" at the bottom of the crank. He might be over doping this with a weak psoas.

Unfortunately if he is an amateur athlete then this willall result in a reduction in road speed initially. But only initially. Amateurs are the most difficult to treat but you have to convince them on this. If he gets the mechanics right the body will heal itself.

Thanks for the update. It's great to hear back on how things are progressing. 8o

[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.

[Bikerphys]

Dear all,

Thanks for all your valuable advice, much appreciated.

Just to update you, my pt. is in the process of recovery !

Had 2 weeks complete rest; during which he was treated by sstm and tp release to biceps femoris and TFL/ITB.
thickening to distal biceps fem/ ITB treated with cross friction massage, (boy did he squeal ! :evil )

stretching and ice application daily, u/s following manual treatment.

Also introduced glut strengthening exs and lumbar spine flexibility exs.

resumed light training with no adverse effects, but rx continued as above. After this a structured increase in training load & intensity has been followed with no recurrence !

pt. feels he has turned a corner and is more positive in his approach.

One thing of note is the return of slight popliteal swelling, but is pain free and can be reduced with effleurage... anyone have any theories on the nature of this ?

Thanks again to all who have offered advice.

[zisuer]

Happy to hear your pt getting better. Usually, if the problem is muscle weakness, it will take coupld weeks to get them better. And there is a new article reported that more than 60% ITBFS pt have lateral knee pain because the bursa underneath the band inflammed, while not the band itself ( a small study though).

[Sports_Rx]

Happy to hear your pt getting better. Usually, if the problem is muscle weakness, it will take coupld weeks to get them better. And there is a new article reported that more than 60% ITBFS pt have lateral knee pain because the bursa underneath the band inflammed, while not the band itself ( a small study though).

Interesting. Can you post a link for the study please? Some recent stuff I'd read was saying the opposite, and questioning whether a bursa was in fact even present under the band. All the anatomy stuff I've looked at shows a juicy fat bursa but it's good to read challenges to the norm

[zisuer]

Yes, it is controversal whether the bursa exists, 90 % stduies reported negative results. But this study reported positive results, it is small study though, but it is new. Here is the paper: Hariri S, Savidge E, Reinold MM, Zachazewski J, Gill TJ. Treatment of recalcitrant iliotibial band friction syndeome with open iliotibial band bursectomy. Am J Sport Med 2009

[ginger]

Restore full non protected mobility to L4 facet joints and by doing you will quickly find reductions and ultimately elimination of this referred pain issue( often erroneously referred to as ITBFS). Best method is known as Continuous Mobilisation, this may take up to fifteen minutes at each L4 facet joint. In some case it may also be necessary to stretch and/or massage piriformis, which commonly assumes a higher state of tone with irritations at the L4 nerve root. Mobs at L4 however will restore a normal state of tone to this muscle , whose anatomical position close to the exit foramen for a large nerve bundle makes it a common corrollory to referred pains to the lateral thigh with L4 hypomobility.
Stop treating the thigh/leg and concentrate your efforts on the nerve irritations causing this problem. Ideas mentioned above in relation to altering seat position, and other biodynamic parameters may be useful in the context of reducing spinal protective behaviour, thus adding to a percieved benefit at the site of referred pain in the thigh/leg.
It is good to remember that all pain happens in the brain, also that all pain can be said to be neural in origin and effect. The only valid questions then are about where and how are nerves involved.

[specialisedsofttissue]

glut med/min weakness can load up TFL and ITB like crazy, these guys typically present with a trendelenberg gait, int rotation of tibia, collapsed arches and valgus hallux. Try some strengthening to glut med/min as well as massage and stretching to TFL. If you dont strengthen the problem will just keep coming back.