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Iliotibial Band Syndrome (ITB Syndrome)

ITB Syndrome: Cause, Cure and Your Core

by Stephen M. Pribut, D.P.M.

Introduction:

Iliotibial band syndrome is one of the top 10 injuries seen in distance runners. Weak hip abductor muscles play a large role in the development of ITB syndrome. These weak hip abductors are part of a commonly seen pattern of weak core muscles. This leads to a muscle imbalance. On longer runs, and as you are just starting to increase the length of your runs, your hip abductors can become fatigued and require the added assistance of the muscles which attach into the ITB to work harder. It seems that this sequence of events may lead to increased tension in the ITB causing the injury. Strengthening the hip abductors and stretching the ITB and structures that attach in to it are usually the keys to recovering from this problem.

Symptoms and Causes:

Symptoms of the iliotibial band syndrome include pain or aching on the outer side of the knee. This usually happens in the middle or at the end of a run. A concomitant problem may occur at the hip called greater trochanteric bursitis. During flexion and extension of the knee the iliotibial band has historically been thought to rub over the femoral condyle creating irritation. There is significant doubt about this being a true "friction" created syndrome. ITBS, in most cases, does not seem to be friction syndrome with a “popping” of the tendon over the femoral epicondyle. Most runners do not report a "popping" feeling. Instead, there is a compression in this region that most often affects the fat tissue overlying the femoral epicondyle. I believe there is significant tension developed during the stance phase of running gait that results in a tendinopathic tendon. Other authors have found some evidence for this. Fairclough has raised the question “Is the iliotibial band syndrome really a fricton syndrome? He contends that the ITB is firmly attached to the femur and is not anatomically capable of moving forward and backwards over the lateral epicondyle of the femur. Recent cadaver studies and MRI studies have failed to document the expected evidence for friction or for a primary anatomical bursa. Instead an area of compression seems to be present in the fat tissue that lies over the lateral femoral epicondyle.

Weak hip abductors, especially the gluteus medius, are often found. Some other factors that may contribute to this syndrome include genu varum (bow legs), pronation of the foot (subtalar joint pronation), leg length discrepancy, and running on a crowned surface. We need to emphasize that over the past few years an association with weak gluteus medius muscles has been found in many runners with ITB syndrome. The weakness of the gluteal muscles causes more tension to develop in the iliotibial band as the muscles inserting into it have to assist in keeping the hips level.

Cyclists may develop iliotibial band syndrome from overuse. Often changing the position of the cletes by rotating the heels inward can help. Be certain to check the bike seat to make certain it is not too high.

“...an association with weak gluteus medius muscles has been found in many runners with ITB syndrome. ”

The function of the muscles inserting into the ITB (Tensor Fascia Lata) is to abduct the leg. If the hip abductors are weak, then the ITB is being overworked. The ITB does not have an insertion that offers a favorable mechanical advantage. In fact, it is at a considerable disadvantage for the purpose of hip and leg abduction activity. Therefore when the hip abductors are weak, the tensor fascia lata must contract harder and over a longer period of time thus straining the ITB. Make sure that part of your cure is to strengthen your hip and leg abductors.

Circular track running may also contribute to ITB, since it stresses the body in a manner similar to that of crowned surfaces and leg length differences. Circular track running was found in research performed on track athletes in the year 2000 to cause asymmetrical muscle strength development. The study did not measure ITB and related muscle strength but found lower down on the leg that the inner leg had stronger inverter strength and the outer leg had stronger everter strength. While it was not studied the outer ITB would likely be placed under much greater stresses than the inner leg. The angles of force acting on it would be greater, just by virtue of the leg and pelvis position requred to run around an oval track. All of these factors can be aggravated by a tight iliotibial band. Changes in training may also contribute to the development of ITB syndrome. It is always important to examine your training regimen and see what alterations have recently occurred. A rapid increase in running distances and times spent running often precedes the development of this injury.

Cyclists may develop iliotibial band syndrome from overuse. Often changing the position of the cletes by rotating the heels inward can help. Be certain to check the bike seat to make certain it is not too high.

Possible Causes:

Anatomy:

The iliotibial band is a thickening of the lateral (outer) soft tissue that envelopes the leg. It starts near the anterior superior ilac spine and inserts into Gerdy's tubercle on the tibia. The thickened tissue is known as fascia and in this area it is called the fascia lata. The thickened band is called the ilio-tibial band (ITB). The muscles that insert into the proximal (upper) portion of this band are the tensor fascia lata and a portion of the gluteus maximus and gluteus medius muscles. During its latter course it splits medially into the ilio-patellar band and laterally into the iliotibial tract. At its insertion into the tibia at Gerdy's tubercle it blends with the Biceps femoris and the Vastus lateralis.

  1. ITB Friction Syndrome:  Diagram

    ITB Syndrome

  2. Hip muscles and ITB

    Hip Abductor Muscles

Self treatment for Iliotibial Band Syndrome:

Make sure you do both the side stretches for flexibility and the hip tilts to strengthen your hip abductors. These exercises are both extremely important and may make a considerable difference in ITB syndrome symptoms.

See: Dr. Pribut's Tips for ITBS Plantar Fasciitis Tips by Dr. Pribut

Side Stretch

The side stretching is performed while standing as follows: Place the injured leg behind the good one. If the left side is the sore side, cross your left leg behind your right one. Then lean away from the injured side towards your right side. There should be a table or chair that you can hold onto for balance on that side. This stretch is the best of several that exist for this area. Be careful not to overstretch. Hold for 7 to 10 seconds and repeat on each side 7 to 10 times. The side stretch stretches the lateral hip capsule, the tensor fascia lata, iliotibial band, and the latissimus dorsi. You'll feel it on your side above your waist in addition to your hip. The arm is held over the head as illustrated to add to the stretching of the lattissimus dorsi muscle. Attachments of the latissimus dorsi lead to the humerus (upper arm bone) and a portion of the lats are connected to the gluteus maximus on both the ipsilateral (same side) and contralateral (opposite side) gluteal fascia. You'll need to stretch both sides and you'll actually may feel some of the stretch on your side.

ITB Stretch - 1

ITB Stretch 2

 

 

 

Hip Abductor Strengthening

The hip abductor's strength may be tested by trying to balance on one leg. You will probably find it difficult to balance on the affected leg. You may strengthen your hip abductor muscles by standing on one leg and lifting or tilting the other hip upward. Keep the knee straight on the leg you are standing on.

 

Video of Hip Tilts - Isolate the Gluteus Medius

 

 

Differential Diagnosis of Lateral Knee Pain and ITBS

Notes On latissimus dorsi muscle:

The "lats" are not often mentioned as contributing to the ITB syndrome in any way. But they clearly can contribute to tightness and have attachments to structures related to the ITB syndrome - the gluteus maximus via the gluteal fascia. Tightness here can restrict motion at the hips and alter the efforts of the gluteal muscles to keep the hips level. Arm swing involves altering the length (and tension) within the latissimus dorsi and connects upper body to the torso and lower body. It's function is to either move the arm or to "raise the trunk in brachiation". Brachiation means "arm swinging" and is how apes, monkeys and chimps (primates) move through the trees. If you are writing a paper and looking for a fancier term, swinging through the trees is also called "arboreal locomotion". The latissimus dorsi also comes into play when you do a chin up, machine pull down, or a "row" with weights.

An article in the Journal of Biomechanics published in March, 2013 (Carvalhais et. al.) reviews force transmission and demonstrated an increase in "passive hip stiffness" and altered hip relaxed position. This gives credence to the theory that they are involved to some degree in the ITB syndrome. This also offers a rationale for why the side stretch is effective in assisting in the treatment.

References:

Carvalhais VO, Ocarino Jde M, Araújo VL, Souza TR, Silva PL, Fonseca ST.
Myofascial force transmission between the latissimus dorsi and gluteus maximus muscles: an in vivo experiment.
J Biomech. 2013 Mar 15;46(5):1003-7. doi: 10.1016/j.jbiomech.2012.11.044. Epub 2013 Feb 8.

Drogset  JO, Rossvoll  I, Grontvedt  T.  Surgical treatment of iliotibial band friction syndrome. A retrospective study of 45 patients.  Scand J Med Sci Sports.  1999;9:296–8.

Fairclough, J., et al., Is iliotibial band syndrome r eal ly a f r i c t ion syndrome? Journal of Science and Medicine in Sport, 2007. 10(2): p. 74-76.

Fairclough, J., et al., The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding. Journal of Anatomy, 2006. 208(3): p. 309-316.

Miller, RH, Lower extremity mechanics of iliotibial band syndrome dur ing an exhaus t ive run. Gait Posture, 2007. 26(3): p. 407-13.

Fredericson M, Guillet M, DeBenedictis L. Quick solutions for the iliotibial syndrome. Physician Sportsmed 2000; 10(3)169-175.

Fredericson  M, Cookingham  CL, Chaudhari  AM, Dowdell  BC, Oestreicher  N, Sahrmann  SA.  Hip abductor weakness in distance runners with iliotibial band syndrome.  Clin J Sport Med.  2000;10:169–75.

Fredericson  M, White  JJ, Macmahon  JM, Andriacchi  TP.  Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches.  Arch Phys Med Rehabil.  2002;83:589–92.

Muhle, C., et al., Iliotibial Band Friction Syndrome: MR Imaging Findings in 16 Patients and MR Arthrographic Study of Six Cadaveric Knees. Radiology, 1999. 212(1): p. 103-110.

Noehren, B. Davis I., Hamill, J. , ASB Clinical Biomechanics Award Winner 2006. Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomech (Bristol, Avon) 2007. 22(9): p. 951-956.

Pribut, SM. The Top 5 Running Injuries. Podiatry Management. 2008: April-May; 117-134.

Pribut, SM. Iliotibial Band Syndrome: Diagnosis and Treatment. Dr. Pribut's Running Injury Web Site. 1999.

Schwellnus MP. Lower limb biomechanics in runners with the iliotibial band friction syndrome. Med Sci Sports Ex: 1993;25(5):S68.

Terry GC, Hughston JC, Norwood LA. The anatomy of the iliopatellar band and the iliotibial tract. Am J Sports Med 1986; 14(1):39-45.


About Dr. Pribut: Dr. Pribut is a member of the Advisory Board of Runner's World magazine. He is a past president of the American Academy of Podiatric Sports Medicine (AAPSM). He served as chair of the AAPSM Athletic Shoe Committee for 5 years and has served on the Education Committee, the Research Committee, the Public Relations Committee and also chaired the Annual Meeting Committee. Dr. Pribut is a past president of the District of Columbia Podiatric Medical Association, serving in that post for 4 years. Dr. Pribut has served as a member of the American Podiatric Medical Association's Clinical Practice Advisory Committee and their Internet Committee. Dr. Pribut is a Clinical Assistant Professor of Surgery at the George Washington University Medical Center.

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