ITB or Not ITB…That is The Question
Treating The Real Causes of ITB Syndrome
I’m writing this article on Iliotibial Band Syndrome as I feel it is a syndrome within sports medicine that is often treated poorly, despite it’s prevalence amongst runners.
I’d like to share with you how I treat runners with Iliotibial Band Syndrome from a biomechanical stand point and the relative success that can be achieved with the correct approach. I am attempting to write in a fashion that will appeal to both clinicians and patients alike but naturally any comments are welcome within the discussion section at the bottom of the article.
Anatomy of ITB Syndrome
Let us start by refreshing our anatomy, which should be the basis of all biomechanics.
The Iliotibial Tract commences with insertional fibres of both Gluteus Maximus and Tensor Fascia Lata and inserts into Gerdy’s Tubercle on the lateral aspect of the tibia, passing over the lateral femoral condyle. To protect the Iliotibial Band from the lateral femoral condyle there is either a bursa (fluid filled sac) or a layer of highly innervated fat that lies underneath the distal portion of the band .
It is essential to remember that the Iliotibial Band is nothing more than a longitudinal fibrous reinforcement of the fascia lata and has no control over its own positioning or tone.
It is often anchored to the intramuscular septum of the femur in a variety of places (this is an anatomical variant) via fascial strands which pass through the periosteum (lining of the bone), rather than merely attaching to the surface.
The tension within the Iliotibial Band will ONLY increase when the origin and/or insertion are moved further apart and we will discuss how this can occur later on.
I would therefore question what one of the most common treatments employed to tackle this syndrome, foam rolling, is physiologically achieving, attempting to release a non-contractile tissue which has the tensile strength of steel and is anchored firmly to cortical bone.
What Causes The Pain of ITB Syndrome?
I would argue that this syndrome is one of compression as opposed to friction .
The pain stimulus within Iliotibial Band Syndrome is usually inflammatory, whereby either the bursa or fat pad is compressed against the lateral femoral condyle. This will occur whenever the Iliotibial Band is shortened by a change at either its origin or insertion.
Common features of inflammatory pain are that it is often worse with compression (for example lying on the affected side) or is most severe first thing in the morning. It will often respond well to oral ‘Non-Steriodal Anti-Inflammatory Drugs’ (NSAIDS), which are not contraindicated in such a condition as there is no collagen based healing that needs to occur.
It is often clinically beneficial to have the region examined under real-time ultrasound scan, which will determine the need for a guided corticosteroid injection, which can provide a positive reduction in symptoms in severely irritable cases. It is here that I will point out that the dreaded foam roller can often exacerbate patients symptoms, by further increasing the compression against the lateral femoral condyle.
1) Hip Flexor Imbalance
One biomechanical flaw that will case a shortening of the Iliotibial Band is Hip Flexor imbalance.
Poor Iliopsoas function will result in a compensatory firing of Tensor Fascia Lata, which has the ability to assist with hip flexion because of its anatomical lever arm [2, 3]. Over a period of time, the length of the Tensor Fascia Lata will reduce (become hypertonic), which means that the Iliotibial Band origin is moved AWAY from the insertion. A secondary consequence is a rise in the anterior hip joint forces and an excessive abduction moment, which is counteracted by an additional compensation within Adductor Longus.
An underactive Iliopsoas muscle is very common within running athletes who have a tendency to use Rectus Femoris, the main Quadricep muscle, to generate hip flexion, instead of Iliopsoas. This is an extremely common running technique flaw.
The hypertonicity of Tensor Fascia Lata can be effectively treated with targeted soft tissue release. In my opinion this is most effectively performed with a large acupuncture needle, to manipulate the myofascial restriction and release any myofascial trigger points within the muscle. However, this can also be achieved with hands-on soft tissue therapy if you prefer.
For those of you that are fans of the dreaded foam roller, please roll local to the Tensor Fascia Lata (roughly near your pocket on a pair of trousers), but remember that muscles and tendons aren’t amazed by compression either, and that you run the risk of causing Gluteus Medius tendinopathy as a result .
2) Dynamic Knee Valgus
The most commonly seen biomechanical flaw in the running population is dynamic knee valgus, a combination of femoral internal rotation with adduction and tibial internal rotation . This will result in the insertion of the Iliotibial Band being moved AWAY from the origin. This pattern of movement was linked to patients in a recent high quality prospective study by Noehren and colleagues .
Dynamic knee valgus can occur as a result of several muscle imbalances but the most common pattern that I see is a weakness/inhibition of Gluteus Maximus. I feel that Gluteus Maximus is more influential than Gluteus Medius in this presentation as it is a three dimensional single joint muscle, the most powerful external rotator of the hip and the superior fibres contribute significantly to hip abduction. Gluteus Medius contributes by fixing the pelvis relative to the femur .
IMAGE © Journal of Orthopaedic & Sports Physical Therapy
3) Contralateral Pelvic Drop
A highly relevant biomechanical flaw within this syndrome is a contralateral pelvic drop. This occurs in single leg stance, with the pelvis dropping down on the non-stance leg relative to the femur in the sagittal plane.
This will result in a subsequent lift of the pelvis on the stance leg, meaning that the origin of the Iliotibial Band is being moved AWAY from the insertion. This occurs as a result of a much more specific pattern of muscle imbalance, whereby Gluteus Medius (stance) and Quadratus Lumborum / External Oblique (non-stance) fail to fix the pelvis relative to the femur.
This pattern often results in over-activity within the lateral trunk on the stance limb and can be a significant contributing factor in patients with unilateral spinal pain.
Key Take Home Messages
- The point that I would like all readers to go away with is that it is muscle imbalance, and not a “tight” Iliotibial Band that causes this common problem and that it is rehabilitation (activation/strengthening) and not compression/stretching that will cure your symptoms.
- Please remember that we are not robots and not all patients will fit into these simple biomechanical boxes.
- People often present with combinations of these movement patterns and certainly dynamic knee valgus can be as a result of many muscle imbalances, which I will happily elaborate on in the discussion section of the blog if the questions arise.
- The challenge for clinicians is to identify them, rehabilitate them and most importantly teach the patient how to transfer what they learn in the gym to their running style.
Please do not throw out the baby with the bathwater. There is still a place for (as examples) soft tissue release of the lateral quadriceps, local anti-inflammatory agents for an acute bursa, kinesio taping (a whole other debate!) to reduce pain and facilitate improved movement; but remember that these techniques treat the symptoms and only rehabilitation of the contributing factors will result in long term improvement.
 Fairclough, J et al (2006). The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat 208, 309-316.
 Lewis, C et al (2009). Effect of position and alteration in synergist force contribution on hip forces when performing hip strengthening exercises. Clin Biomech 24 (1), 35-42.
 Lewis, C et al (2007). Anterior hip joint force increases with hip extension, decreased gluteal force or decreased iliopsoas force. J Biomech 40 (16) 3725-3731.
 Cook, J & Purdam, C (2012). Is compressive load a factor in the development of tendinopathy? Br J Sports Med 46, 163-168.
 Distefano, L et al (2009). Gluteal muscle activation during common therapeutic exercises. JOSPT 39 (7), 532-540.
 Noehren, B et al (2007). Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomech 22, 951-956.
 Powers, C (2010). The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. JOSPT 40 (2), 42-51.
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