Iliotibial band syndrome

Iliotibial band syndrome, aka ITBS or ITBFS (for Iliotibial Band Friction Syndrome), is a common injury generally associated with running. Additionally it can also be caused by biking, hiking or weight-lifting (especially squats).

Definition

Iliotibial Band Syndrome is one of the leading causes of lateral knee pain in runners. The iliotibial band is a superficial thickening of tissue on the outside of the thigh, extending from the outside of the pelvis, over the hip and knee, and inserting just below the knee. The band is crucial to stabilizing the knee during running, moving from behind the femur to the front of it during the gait cycle. The continual rubbing of the band over the bone, combined with the repeated flexion and extension of the knee during running may cause the area to become inflamed or the band itself may become irritated.

Symptoms

The symptoms range from a stinging sensation just above the knee joint on the outside of the knee or along the entire length of the iliotibial band to swelling to a thickening of the tissue at the point where the band moves over the femur. The pain may not occur immediately, but will worsen during activity when the foot strikes the ground if you overstride or run downhill, and may persist afterward. A single workout of excessive distance or a rapid increase in weekly mileage can aggravate the condition, especially if other predispositions exist.

ITBS can also occur at the hip joint, where the IT band connects to the hip. It is less likely to occur at the hip as a sports injury. It can commonly occur during pregnancy, as the connective tissues loosen to allow for delivery at the same time the women gains weight, adding more pressure. The hip version also commonly affects the elderly. This version is much less-commonly studied and few treatments are generally known.

Causes of Injury

Iliotibial Band Syndrome is the result of both poor training habits, equipment and anatomical abnormalities.

• Running on a banked surface, such as the shoulder of a road or an indoor track, causes the downhill leg to bend slightly inward and causes extreme stretching of the band against the femur.
• Inadequate warm-up or cool-down.
• Running excessive distances or increasing mileage too quickly can aggravate or cause injury.
• Anatomical abnormalities such as bowlegs or tightness about the iliotibial band.
  • One common indicator of bowleggedness for runners is that the outside of your sneaker's heel will have excessive wear, compared to the inside.

Treatment

If the athlete had acute ITBFS I would have them reduce their weekly mileage by at least ½ for 2 weeks, during this time the athlete would only be running on flat ground. After this time, and after trying to identify and correct anything that could have been causing the pain, if the athlete has not been feeling any pain I would suggest that he slowly start to build up his mileage again. He would have to do this while ensuring to retain pain free.

If the athlete had chronic ITBFS then he would have to stop running immediately for, at a minimum, two weeks. If the pain and inflammation are still there after this time, and treatment, I would then recommend that another four weeks may be needed, while persisting with treating the injury. Once the injury began to improve a return to activity could be possible, doing low mileage, low speed jogging on flat terrain. To try to prevent, or cure chronic ITBFS there are things that are essential:

o Strength building and maintenance is crucial in controlling ITB tightness. o All of the proximal hip musculature, especially the straight leg raising motion and hip adduction need to be strengthened. o The athlete should also continue to do specific stretches. o The athlete should also strengthen the hip flexors and stretch the gluteus maximus muscles.

To create a good treatment program, you have to look at how bad the injury is. Only once the injury has been properly assessed can you begin a program, there are normally three main phases to recovery: 1. The Immediate Phase 2. The Short Term Phase 3. The Long Term Phase

Immediate Phase of treatment

Begin with the immediate phase of treatment. To start control pain and inflammation. To control and reduce inflammation and swelling RICE (Rest, Ice, Compression, and Elevation) is very good. It is also important to look at what may have caused ITBFS, it could be poor training habits or structural abnormalities and these need to be corrected. Minor abnormality in your foot anatomy, like high or low arches, and the force of the foot strike is passed to the knee area, which can lead to ITBFS, other abnormalities such as cavus feet, uneven leg length and runners who overpronate are also more likely to suffer the injury, the trainers that the runner uses are also very important, After 500 miles most shoes retain less than 60% of their initial shock absorption capacity. To achieve these goals the athlete must reduce, or even stop, his training, depending upon the severity of the injury. Anti-inflammatories and many other things like ultra sound and electrical stimulation are also very useful during this phase, as well as stretching exercises to make sure that the iliotibial band does not become tight.

Short-term phase of treatment

If the pain and inflammation are not gone within ten days then I would begin the short term phase. After this time I would advise that all painful activity be stopped, while continuing with the treatment methods above. Steroid injections, given every two weeks, are also very useful. To try and maintain as much fitness as possible during this phase I would recommend swimming to the athlete, as long as this is pain free. Running in the deep end of a swimming pool, where the athlete can not stand, with a life jacket on is very effective for retaining fitness; this is what I would recommend for our athlete, as long as it is pain free. Cycling is also an option, although it is much more likely than swimming to cause pain.

Last-Phase of treatment

The last phase is the long term phase and is only started once pain and inflammation are gone, a period of time that varies hugely. This phase often involves the athlete returning to competitive sport. The most important thing during this time is to ensure that none of the old symptoms recur; this means that any pain or inflammation must be treated with caution, especially if the ITBFS was serious and involved a lengthy lay off. The return to sport must be gradual and treated with extreme care, structurally specific stretching during this time is essential and needs to be done, extensively, before and after activity. The return to activity should be done while correcting, or significantly reducing, any factors that were thought to have caused ITBFS, if no factors were identified and corrected the chance of the injury re-occurring are much higher. Before returning to activities there are three main criteria that must be satisfied before considering returning to action:

• Injured knee has regained full range of motion without pain.
• Injured knee has regained normal strength comparable to the uninjured knee.
• Athlete’s cardiovascular endurance has returned to normal

The length of time spent on each phase can vary hugely, depending on the athlete, the reasons for the initial injury and the severity of the injury. As soon as ITBFS is suspected, however mild, there are some tips that can be followed to decrease pain; these tips are also very good for athletes returning to activity after time out for ITBFS:

• Decrease your mileage and apply ice after you run.
• Changing your route, if you often run the same, is sometimes good. If you run on a track it is useful to run around it in both directions, constantly running one way puts increased stress on the iliotibial band of just one leg.
• Pain is aggravated by repetitive flexion of the knee and is relieved by walking stiff-legged.
• Running downhill is to be avoided at all costs as this aggravates the pain, which is most intense at heel strike.
• Look for signs of increased foot pronation, and try to correct this if there are signs.
• Maintenance of range of motion through continuation of exercises previously practiced during supervised therapy sessions.
• Alteration of running and cycling workouts to flat surfaces with fewer hills or speed workouts.
• Use of proper footwear to control ankle pronation or excessive rearfoot varus.
• Rest from aggravating activities.

Rarely, and only in extreme cases, surgery is used to try to correct the injury, and I would definitely not recommend this for our athlete, unless he was still suffering from symptoms in 6 months to a year. This involves the release-excision of the iliotibial band, but is only done after an arthroscopic evaluation of the knee, which rules out other causes for the symptoms. Surgery is only performed for athletes who are unwilling to adapt their exercise because of this injury, for instance refusing to reduce their mileage. It is also only done after all other treatments have failed.

In order for successful rehabilitation it is essential to restore the flexibility of the iliotibial band, as well as the strength and flexibility of the muscles which act on it. Before the band can be stretched hip flexion will need to be stretched. Stretching the band is a complicated task, although it is essential, and very effective, for recovery. To effectively stretch it is necessary to heat the lateral thigh with hydrocollator packs for twenty minutes. This is followed by ultrasonic heating (1.5-2.0 watts/cm2) to the length of the ITB tract for 5-7 minutes. After this is done a two-man OBER manoeuvre, where one therapist stabilizes the pelvis while the other therapist stretches the leg into maximally tolerated adduction is performed. This is best done using three one minute stretches. (Gose et al.) Cryotherapy of the painful and inflamed tissue for ten minutes in the stretched position is very effective and what I would recommend for our athlete.

Staying in Shape while Not Running

If you don't want to lose all your conditioning, try some of the following:

• Deep-water pool running
• Swimming with any kick except the "frog kick", whose whip-like action could aggrevate your IT.
• Speed walking with straight legs on flat surfaces.
• Cross-country skiing, especially on machine (keep legs fairly straight).
• Pilates
• Yoga

Sports Activities to Avoid while you're Symptomatic

• StairMasters
• Dead-lifts
• Step Aerobics
• Court sports, such as tennis, racket ball, squash, basketball

Long Term Treatment

To treat structural abnormalities such as a natural tightness in the band:

• Stretching, especially before working out, to make the band more flexible and less susceptible to injury.
• To check for anatomical abnormalities, have a physical therapist familiar with ITBS videotape your running form on a treadmill and look at your body mechanics.
• In extreme cases, surgery to relieve tightness in the band. However, surgery is not always effective.

Both structural and functional problems need to be considered when treating Iliotibial Band Syndrome.

After the Pain is Gone

• You should not start running as soon as the pain stops.
  • If you have chronic ITBS, you may have to wait 2 weeks after the symptoms are gone.
• Restart running with minimal mileage, building slowly.
  • As you build your mileage, stop as soon as you feel pain.
    • Even better, try to stop running before the pain starts.
• Continue stretches, as well as strengthing of your quads and glutes.

Additional Treatment Options

• Deep-tissue massage or Rolfing may help break up scar tissue that forms.
• Non-steroidal anti-inflammatory drugs (aka NSAIDs), in high doses for a period of weeks, can help reduce the inflammation.
• Strengthening exercises for the quadriceps femoris and gluteus medius muscles can help support the leg, thus lessening the load on the ITB.
• Cortisone shots have been used to help reduce the inflammation, though some risks are involved with this treatment.

Disclaimer

As with any injury or ailment, you should see your doctor or physical therapist for diagnosis and treatment, rather than relying solely on advice you get from the Internet.

References and Links

• Information provided by the American Running and Fitness Association, and other sources.
• Sports Medicine Tent: ITB

• Iliotibial Band Syndrome information website