Iliotibial Band Syndrome, commonly abbreviated as ITBS, is a frequent overuse injury experienced predominantly by runners, cyclists, soccer players, skiers, and weightlifters. This syndrome is a leading cause of pain on the outer side of the knee. Traditional treatments often fail to fully alleviate the symptoms of ITBS, primarily because they typically do not target all the critical structures implicated in this injury.
Traditional Viewpoints
In conventional understanding, ITBS is perceived as a friction syndrome where the iliotibial band constantly rubs against the lower part of the leg (specifically the lateral femoral epicondyle of the femur). The theory suggests this happens as the iliotibial band shifts back and forth during knee bending and straightening. This continual movement leads to friction, microscopic tears, and swelling in the area, including a bursa between the lateral epicondyle and the IT band.
Many researchers have found that the peak pain is typically experienced at approximately 30 degrees of knee flexion, often called the zone of impingement. This was indeed the understanding imparted to me during my orthopedic classes almost three decades ago. This line of thought also forms the basis of the treatment plans most practitioners come up with. However, this perspective, as it turns out, is INCORRECT…
Insights from Recent Research
The traditional viewpoint of ITBS has been significantly challenged in light of recent research findings. This primarily stems from identifying anatomical elements that effectively hinder the iliotibial band from moving back and forth. Studies have shown that the iliotibial band is securely attached to the leg (specifically the linea aspera of the femur) by a layer of robust connective tissue known as the intermuscular septum. (1)
Moreover, the band is also connected by strong fibrous strands just above the knee (at the lateral epicondyle) and extends deeply into the bone. These firm attachments prohibit the iliotibial band from moving front and back over the lower leg (lateral epicondyle), as was previously believed.
The Structure and Role of the ITB
The iliotibial band (ITB), from an anatomical perspective, is a densification of a structure called the fascia lata. The fascia lata is a network of connective tissue (fascia) that entirely envelops your leg. You can imagine the fascia lata as a sock that wraps around your entire thigh.
Situated on the outer aspect of your thigh, the iliotibial band (this thickened fascia) is not a separate entity but an integral part of the fascia lata. This fact makes the theorized back and forth movement virtually impossible since it cannot slide independently.
Furthermore, the iliotibial band is a component of a structure referred to as the "Pelvic Deltoid Complex". In this complex, the superficial layers of the gluteus maximus muscle from the rear hip and the fibers from the tensor fascia lata muscle at the front of the hip converge into the iliotibial band. These muscles work together to lift the hip to the side (hip abduction). They also support the gluteus medius muscle (another abductor) in keeping the pelvis in a neutral position when standing on one leg (Stance Phase of Gait).
Focus on Hip Strength, Not IT Band Length
When hip muscles weaken, there's an increased inward movement (adduction) of the leg. This is most noticeable during the Stance Phase of Gait. Such inward movement intensifies the force exerted through the iliotibial band, leading to the compression of the tissue at the outer knee.
This exact observation has been made in individuals suffering from ITBS. These individuals have weaker gluteal muscles (abductors) and an increased inward movement (adduction) of the hip during the Stance Phase of Gait. (2)
The Real Issue is the Fat Pad, Not the Bursa
Previously, we discussed the conventional belief that pain arises from the compression of the bursa (a fluid-filled sac found between anatomical structures). Regrettably, MRI studies have revealed no bursa between the IT band and the outer knee. Biomechanically, there's no necessity for a bursa in this area, as without the assumed back-and-forth movement, there's no requirement for friction reduction.
However, a layer of highly innervated fat, packed with neurological receptors, is present in the area between the IT band and the outer knee (the pain site). Compression of this region is most likely the primary cause of outer knee pain in Iliotibial Band Syndrome. (4)
Accurate Diagnosis for ITBS Patients
It is paramount that every patient suspected of having ITBS undergoes a thorough examination using specialized orthopedic, neurological, and vascular assessment procedures. This is vital to accurately determine the nature of the condition and rule out any underlying pathologies. These assessments can help us understand more than just the symptoms; they can unveil the root cause of the problem, allowing for more targeted and effective treatment strategies.
The upcoming videos will visually demonstrate some common procedures we utilize with our patients.
Orthopedic Knee Assessment - A Comprehensive Approach to Knee Examination
The following video showcases a selection of standard orthopedic tests we employ in our patient knee examinations. These methods are essential tools in our diagnostic toolkit, helping us understand the complexities of each patient's condition.
Neurological Assessment of the Lower Limbs
The neurological examination of the lower limbs is crucial to the broader neurological examination process. It evaluates the motor and sensory neurons serving the lower extremities. This evaluation assists in identifying any potential dysfunction in the nervous system. The examination serves a dual role: it is both a preliminary screening tool and a method for in-depth investigation of neurological issues.
Essential Aspects of Peripheral Vascular Examination
A peripheral vascular examination is a crucial diagnostic tool employed to exclude indications of vascular-related disorders. Recognizing and treating Peripheral Vascular Disease (PVD) can significantly reduce the risk of cardiovascular and cerebrovascular complications.
Treatment Approaches
Iliotibial Band Syndrome (ITBS) treatment strategies can involve various procedures, such as myofascial release and osseous manipulations. The techniques employed will significantly depend on the structures involved in the larger kinetic chain, emphasizing the importance of a thorough and accurate diagnosis.
In many cases, we undertake muscular work spanning from the hip down to the foot, approaching from various angles. This comprehensive approach ensures that we address the issue from all possible directions, thereby enhancing the effectiveness of the treatment.
Moreover, we aim to alleviate any restrictions present in the pelvic area, specifically focusing on the sacroiliac (SI) joints. These joints link the spine to the hips, and any limitations here could contribute to ITBS symptoms.
We also target any peripheral joint restrictions in the knee or ankle. These joints play a critical role in lower limb movement, and addressing issues here can further contribute to relieving ITBS symptoms.
Our approach to treating ITBS is holistic, considering the interconnectedness of various body structures. We aim not just to alleviate immediate symptoms, but to address the root cause of the problem, thus providing a long-term solution for our patients.
Personalized Knee Pain Protocol - Motion-Specific Release
Every instance of knee pain should be treated as a distinct dysfunction unique to the individual experiencing it. Sometimes, the issue may be localized, affecting only nearby structures. In other cases, the issue might encompass a broader kinetic chain, impacting a larger interconnected network of body structures.
I'll demonstrate that the Motion-Specific Release (MSR) procedures have proven highly effective in managing knee pain associated with ITB Syndrome. Targeting specific areas and movements causing pain can significantly improve the patient's condition, relieving discomfort and enhancing mobility. They are integral to our comprehensive and tailored approach to treating knee pain and ITB Syndrome.
The Role of Chiropractic Manipulation in Treating ITBS
Chiropractic manipulation plays a crucial role in the treatment of ITBS. This therapeutic approach emphasizes the importance of addressing the body's kinetic chain, which includes joints from our hips down to our feet.
The kinetic chain refers to the interconnected group of body segments, and movement in one segment can influence movement in others. Therefore, in conditions like ITBS, it's essential to consider the body as a whole rather than focusing solely on the area where the pain is most evident.
Neglecting these critical structures can make resolving chronic cases of ITBS significantly more challenging. Therefore, comprehensive chiropractic manipulation aimed at these key elements of the kinetic chain is a vital part of an effective treatment strategy for ITBS.
Enhancing Knee Joint Mobility in ITB Syndrome - 4 Point Knee Joint Mobilization (MSR)
Enhancing knee joint mobility is crucial in effectively addressing the full kinetic chain, particularly when dealing with conditions like ITB Syndrome. The success of any myofascial treatment can be significantly impacted if we do not concurrently manage restrictions in joint mobility.
In the context of ITB Syndrome, knee joint mobility plays an integral role. The syndrome often results in restricted knee movement, which can affect the overall function of the kinetic chain. Therefore, a key part of the treatment strategy involves improving this mobility to help restore normal movement patterns and alleviate symptoms.
The Role of Exercises in Addressing Iliotibial Band Syndrome
Physical exercises play a pivotal role in the successful resolution of ITB Syndrome. An effective exercise regimen for ITBS must encompass flexibility and mobility exercises, strengthening activities, as well as balance and proprioception training. These combined aspects work together to enhance muscle function, improve joint mobility, and ultimately alleviate the symptoms of ITBS.
The exercises we prescribe are tailored to each patient's specific needs and conditions. There is no one-size-fits-all solution when it comes to exercise therapy for ITBS. Therefore, the type and intensity of exercises we recommend will vary significantly from one case to another.
The following are examples of exercises that we frequently prescribe for ITBS. However, it's important to note that these examples are illustrative and may not be suitable for every patient. An individualized approach, considering each patient's unique needs and capabilities, is the cornerstone of our exercise prescription strategy for managing ITBS.
Iliotibial Band Relief Using a Ball
The video demonstrates a technique to use a ball to alleviate tension in your Iliotibial Band. The Iliotibial Band is an inherently sturdy structure in your body - it needs to be, given its role as a swing spring.
While rolling and stretching exercises can enhance fluid exchange and alleviate pressure on nearby anatomical structures, they won't lengthen the IT Band. However, these exercises are crucial in managing ITB Syndrome by reducing discomfort and improving the band's overall function.
Effective Gluteal Muscle Release - Lacrosse Ball
This is an extremely effective way (combined with stretching) to release restrictions in the gluteal muscles. That being said, don't forget to strengthen the glutes.
15-Minute Butt and Thigh Workout
Strengthen and Tone Your Glutes - When it comes to strengthening your buttocks, thighs, and legs, incorporating this exercise program into your fitness routine can yield impressive results. Doing this program every other day for 4-6 weeks with consistency and commitment can lead to substantial gains.
Improve Your Balance - Advanced Exercise
Balance exercises can be of great benefit to people of any age. Balance exercises improve your ability to control and stabilize your body's position. Balance exercises greatly reduce injury risk, rehabilitate current injuries, or increase your sports performance.
Conclusion - Iliotibial Band Syndrome
In conclusion, the comprehensive treatment of Iliotibial Band Syndrome (ITBS) requires a multi-faceted approach that addresses the body's complete kinetic chain, from the hips down to the feet. Traditional perspectives of ITBS have evolved due to more recent research, highlighting the importance of hip strength and the role of the fat pad in the lateral knee rather than the previously assumed bursa.
By utilizing techniques like myofascial release, osseous procedures, chiropractic adjustments, joint mobilization, and personalized exercise regimens, we can better manage ITBS. Each patient's case is unique, and the treatment protocols must be equally individualized to ensure optimal recovery and prevent recurrence.
Moreover, routine evaluations, including orthopaedic, neurological, and vascular exams, cannot be overstated. These assessments allow us to diagnose the condition accurately, rule out other pathologies, and formulate effective treatment strategies.
Overall, the key to successful ITBS treatment lies in a holistic and patient-centric approach that acknowledges the interconnectedness of our body structures and targets not just the symptoms but the root cause of the condition. With the right guidance and commitment to treatment, patients can effectively overcome ITBS and regain their mobility and quality of life.
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson is committed to running an evidence-based practice (EBP) incorporating the most up-to-date research evidence. He combines his clinical expertise with each patient's specific values and needs to deliver effective, patient-centred personalized care.
As the Motion Specific Release (MSR) Treatment Systems developer, Dr. Abelson operates a clinical practice in Calgary, Alberta, under Kinetic Health. He has authored ten publications and continues offering online courses and his live programs to healthcare professionals seeking to expand their knowledge and skills in treating musculoskeletal conditions. By staying current with the latest research and offering innovative treatment options, Dr. Abelson is dedicated to helping his patients achieve optimal health and wellness.
References
Is iliotibial band syndrome really a friction syndrome?Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M J Sci Med Sport. 2007 Apr; 10(2):74-6; discussion 77-8.
Hip abductor weakness in distance runners with iliotibial band syndrome. Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA Clin J Sport Med. 2000 Jul; 10(3):169-75.
Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee:implications for understanding iliotibial band syndrome. J Anat. 2006;208:309-316
The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome J Anat. Mar 2006; 208(3): 309–316.
The Harvard Gazette - "Understanding the IT Band"
Falvey, E.C., Clark, R.A., Franklyn-Miller, A., Bryant, A.L., Briggs, C., & McCrory, P.R. (2010). Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scandinavian Journal of Medicine & Science in Sports, 20(4), 580-587.
Fredericson, M., & Wolf, C. (2005). Iliotibial band syndrome in runners: innovations in treatment. Sports Medicine, 35(5), 451-459.
Ellis, R., Hing, W., Reid, D. (2007). Iliotibial band friction syndrome—A systematic review. Manual Therapy, 12(3), 200-208.
Noehren, B., Davis, I., & Hamill, J. (2007). ASB Clinical Biomechanics Award Winner 2006 Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clinical Biomechanics, 22(9), 951-956.
Orchard, J.W., Fricker, P.A., Abud, A.T., & Mason, B.R. (1996). Biomechanics of iliotibial band friction syndrome in runners. The American Journal of Sports Medicine, 24(3), 375-379.
Straub, R.K., & Khayambashi, K. (2018). Iliotibial Band Syndrome: Evaluation and Management. Journal of Orthopaedic & Sports Physical Therapy, 48(12), 911-916.
van der Worp, M.P., van der Horst, N., de Wijer, A., Backx, F.J., & Nijhuis-van der Sanden, M.W. (2012). Iliotibial band syndrome in runners: a systematic review. Sports Medicine, 42(11), 969-992.
Fairclough, J., Hayashi, K., Toumi, H., Lyons, K., Bydder, G., Phillips, N., Best, T.M., & Benjamin, M. (2006). The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of Anatomy, 208(3), 309-316.
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