Iliotibial Band Syndrome

As I mentioned in my race report, I have come down with IT Band Syndrome (ITBS) outside my right knee.  I had the exact same episode in March 2009 on my left side so it's an all too familiar feeling.  I haven't run in 7 days because of it causing a wave of running depression and realization of how important it is for my day-to-day living.  Since I am in grad school for PT I wanted to share some facts and experience with ITBS should you ever have the unpleasant experience of having to manage it.  Some anatomy for starters: the ITB is a thickening of the connective tissue surrounding your thigh.  All muscles are sheathed in usually thin connective tissue called fascia but in the leg is thickens quite dramatically on the lateral aspect of the thigh and the two main muscles that connect to it are the tensor fascia lata (TFL) and gluteus maximus (GM).  The TFL is located just lateral to your anterior superior iliac spine (ASIS) which are these bony prominences of the pelvis on your front side. You can easily palpate them on yourself: you have one on each side.  If you move your fingers 3cm to the outside of both ASIS and 1cm down you'll feel the small muscle which is the TFL.  Now run your hand along the outside of your thigh until you get to your knee; the whole thing is the ITB and it's insertion points in the area are vast: lateral patellar retinaculum, fibular head, Gerdy's Tubercle (tibia), biceps femoris (lateral hamstrings), and vastus lateralis (quadriceps).  The TFL does several things: flexes your knee when it's <20 degrees, flexes and internally rotates your hip.  When you flex your knee at about 20-30 degrees (from a standing position) a portion of the ITB that was infront of the lateral femoral condyle of your knee glides across it setting itself up behind the condyle.  To allow this smooth repetitive transition there is an underlying bursa, a fluid filled sack lying between the bone and ITB allowing an almost frictionless glide.  The school of thought behind why the ITB is even there is to keep the vast musculature of the thigh "in check".  One of the events that happens to the ITB if not properly managed is adhesion formation to the underlying muscles and superficial skin that doesn't allow correct biomechanical properties to take place.  This may lead to more pressure on that femoral condyle thus disrupting that smooth gliding occurring everytime you flex your knee.  Friction starts to occur damaging the tissue and bringing in inflammatory agents to the area.  The more swelling there is the more pressure and less room there is for the ITB to function. Therefore, the more you flex your knee while in this phase, more inflammation sets in, irritating surrounding nerves and activating pain stimuli. You can see how this would become a vicious cycle if left unchecked. In March 2009 this happened to me during a trail race and I couldn't bend my knee 5 degrees without creating severe pain.  There are other biomechanical reasons why the ITB can cause a lot of problems: the latest research has been pointing to the hip musculature to control femoral rotation (weak hip extensors/stabilizers: gluteus medius), shortened hip flexors (which causes the TFL to be overused), quadriceps, adductors, and hamstrings.  So how to manage this type of functional injury (I am not addressing structural dysfucntions such as leg length discrepancy, tibial varus, etc) :

1) decrease inflammation: as long as there are inflammatory properties in the area you cannot begin the healing process. Use ice religiously and anti-inflammatory medications (ask your physician)
2) use a foam roller to make sure the underlying fascia is seperate from the superficial skin and muscle. One may use skin rolling technique to determine areas of adhesions.
3) gluteus medius strengthening, hip external rotation strengthening
4) lengthen shortened musculature of hip and knee (to restore biomechanics), especially adductors on affected side because of possible reciprocal inhibition of glut medius if restricted and overused as hip stabilizers
5) deep friction mobilization at tender site (to break up scar tissue and decrease pain)
6) avoid running on banked surfaces (ie side of road)
7) cross training/rest

See how things react after certain self treatments. Not everyone is the same so things that might work for one person isn't necessarily going to be as effective for another.

So these past 9 non-running days I have been doing most of the above while taking both steroidal/non-steroidal anti-inflammatory medications (Prednisone and Meloxicam).  It has been improving but truthfully it's been quite depressing not running. These moments certainly make me aware that I need to practice what I preach.  Flexibility and strength: how do I expect to have a healthy body overtime when I don't keep it well maintained? The fact is it constantly needs attention and care, especially with the amount of work it goes through.  I also am doing a research paper on barefoot running vs. running shoes in relation to runner's injuries and rehabilitation. I know this is a new field so the research might be a little on the thin side but I am quite interested in what I find. I'll keep the blog updated when I delve into the research. Now I am obviously not a PT yet but if you have any musculoskeletal related questions I can certainly answer them the best I can using my current knowledge and experience. Just leave a comment.

Comments

  1. Hey Mike,

    Are you getting any kind of advice on whether ITBS should require maintenance medication support. I.e., What's the cutoff point where training regimens should be changed to avoid chronic use of NSAIDs and SAIDs?

    -J

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  2. Good question. Ideally, we should immediately alter regimens preferably before any injuries actually occur. It's my belief that there is a certain threshold of where one minute we seem fine and the next we're injured. We might think it happened suddenly but in reality we were getting closer and closer to that threshold and then one day it finally crosses that line. So the further we can distance ourselves from that injury threshold the better off we are (ie prevention).
    The side effects of taking NSAIDS/SAIDS over a prolonged period of time range from gastric bleeding to liver dysfunction issues. The answer would then be no in regards to using it for a prolonged period. It probably should be used for a short period of time and for acute cases. To treat the underlying, less obvious, cause and not just the symptom you have to examine the biomechanics of that individual including muscular strength of the hips, range of motion (ie flexibility), gait pattern, mechanism of injury etc. That will be most important in solving the problem and preventing it from reoccurring.

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