Iliotibial band friction syndrome

“Content” that you can learn about:

Ø Overview of “ITBFS”

Ø What is the Iliotibial Band?

Ø Epidemiology

Ø What is the iliotibial band?

Ø Anatomy

Ø Pathophysiology

Ø Etiology

Ø Other factors frequently reported are the following:

Ø Mechanism of injury

Ø Who are mainly suffer from “ITBFS”

Ø Clinical features of “ITBFS”

Ø How is ITB syndrome diagnosed?

Ø Video:

Ø Physical test

Ø Result

Ø Prognosis

Ø Prevention of IT band syndrome:

Ø Here some tips to avoid ITB friction

Ø Difference between ITBFS & TFL

Ø ITBF syndrome treatment

Ø Advice to the patient of ITBFS

Overview of ITBFS:

ITBFS is a common cause of lateral knee pain. It also known as “Runner’s Knee”.

A statistics show that 22% Of ITBFS is caused by overuse injury in runner’s.

In this case Biomechanical and Training factors play a large role in the development of ITBFS. But its exact cause is elusive.

Iliotibial band friction syndrome (ITBFS) is an inflammatory, non-traumatic, overuse injury of the knee affecting predominantly long-distance runners.

Most cases of ITBFS can be treated successfully with conservative therapy.  Recalcitrant cases of ITBFS may require other interventions, such as cortisone injections and/or surgery.

Epidemiology:

Overall incidence of ITBFS in the general population is not well reported. Depending on which population is examined, the incidence is in the range of 1.6-52%. It varies with the target population's type and intensity of activity. ITBFS was the most common specific injury and accounted for 22.2% of all lower-extremity injuries. Runners experience 12% of all running-related overuse injuries from ITBFS. 

What is ITBFS?

The ITB, or iliotibial band, is a long, thin band of fascia that runs down the outside of thigh. At the top of thigh, it is attached to the Tensor Fascia Latae (TFL) muscle, and Gluteus Maximus and at the bottom it attaches to the tibia (lower leg bone) and femoral condyle on lower outside portion of the thigh bone.

Anatomy of ITB:

•      The ITB originates from the outer lip of the anterior iliac crest, the anterior border of the ilium, and the outer surface of the anterior superior iliac spine. The tensor fasciae latae originates here also, and its fascia blends with the ITB at the lateroanterior thigh one third of the way distally. 

•      The primary synergistic muscles are the hip abductors. These muscles are the gluteus medius, gluteus minimus, and the upper fibers of the gluteus maximus. Their nerve supply comes from the superior gluteal nerve, which is a branch off of the L4, L5, and S1 nerve roots.

Pathophysiology:

ITBFS typically is observed in people who exercise vigorously. The overuse creates stress that the body cannot repair, and soft tissue breakdown occurs.

Etiology:

ITBFS usually is caused by overuse, mostly due to errors in training. Single session errors cause ITBFS as often as repetitive deficiencies. Sudden changes in surface (ie, soft to hard, flat to uneven or decline), speed, distance, shoes, and frequency can break down the body faster than it can heal, causing injury.

Essentially ITB friction syndrome is caused by altered running biomechanics due to underlying muscular imbalances. Once biomechanics can alter due to a muscle imbalance (weakness or tightness), fatigue and ground impact issues.

Other factors frequently reported are the following:

•      Limb-length discrepancy

•      Genu varum

•      Over pronation

•      Hip abductor weakness

•      Myofascial restriction

•      Poor biomechanics (running technique); particularly inwards rolling knees and hips

•      Weak hip / gluteal muscles

•      Weak hip rotators

•      Weak inner quadriceps

•      Weak core muscles

•      Poor foot arch control

•      Worn out or unsuitable runners

•      Sudden increase in mileage for training

•      Excessive hill training (particularly downhill)

Who are mainly suffer from “ITBFS”?

1.   Athletes

2.   Distance Runner

3.   Down heel walker

4.   Army

Clinical features:

•      Sharp or burning pain just above the outer part of the knee

•      Pain that worsens with continuance of running or other repetitive activities

•      Swelling over the outside of the knee.

•      Pain during early knee bending 

•      Gradual onset of symptoms which if they persist for greater than 4 weeks can cause major sport or activity interference.

How ITBFS is diagnosed?

•      ITBFS can be diagnosed by physical examination, a physiotherapist or a sports doctor will look for signs of ITB Friction Syndrome. The important diagnosis is discovering “what is causing” the problem. If this isn’t determined ITB friction syndrome will persist on a return to running. With a thorough assessment, further investigations, such as scans are required.

Physical test:

Noble’s test:

•      The Noble’s test (also known as Noble's Compression test) is a provocative test of the iliotibial band, developed by Clive Noble. It is commonly used as an indication for iliotibial band syndrome; however, no evidence-based research has been done yet to control the validity of this test. Other tests that could be used are the modified Ober’s test and the Rene Creak test.

Purpose:

•      The purpose of this test is to detect pain, abnormalities, tightness of the iliotibial tract, which can be indicative for the iliotibial band syndrome. It helps to differentiate iliotibial band syndrome from other common causes of lateral knee pain.

Technique:

•      Put the patient in a supine position. Next bring the affected knee up to a 90 degree knee flexion and apply pressure with your thumb to the lateral femoral epicondyle. The leg is then extended slowly. When it is extended to approximately 30 degrees, the iliotibial band translates anteriorly over the lateral femoral epicondyle under the examiners thumb.

•      If the patient indicates pain at this 30 degree angle, which is similar to when the patient is active, the test is considered positive and it suggests the presence of iliotibial band syndrome.

Ober’s test:

•      The Ober's test evaluates a tight, contracted or inflamed tensor fasciae latae (TFL) and iliotibial band (ITB). There are 2 variants of the test:

•      Ober’s test: The patient lies on the uninvolved side with hip and knee flexed in a 90-degree angle. The examiner placed the knee in a 5° flexion angle, fully abducts the lower extremity that needs to be tested, then allows the force of gravity to adduct the extremity until the hip cannot adduct any further. (figure 1A)

•      Modified Ober’s test: The patient is positioned on the side of the unaffected leg with the hip in neutral position and the knee in full extension. (figure 1B)

Purpose:

The Ober's test is performed to assess for tightness of the ITB and the TFL along the lateral aspect of the hip and thigh.

Test position:

•      Patient should be in sidelying with the affect side up

•      Bottom knee and hip should be flexed

•      For consistency in testing, some suggest using top hand and arm to be placed under the flexed knee holding onto the side of the table. Note the angle of the hip and knee which should be near 90/90. This may allow for better reproduction for future testing

Test:

•      Extend and Abduct the hip joint

•      Slowly lower the leg toward the table -adduct hip- until motion is restricted

•      Ensure that the hip does not internally rotate during the test and the pelvis must be stabilized to maintain position

Result:

1.  If the ITB is normal, the leg will adduct and the patient won't experience any pain, in this case the test is called negative.

2.  If the ITB is tight, the leg would remain in the abducted position and the patient would experience lateral knee pain, in this case the test is called positive.

Prognosis:

•      Most patients with ITBFS recover with conservative therapy and enjoy good prognoses. One study in 1992 documented 19 athletes with ITBFS, and all were treated successfully without surgery.

•      Those who require surgery often do well. Surgical release of the ITB is typically successful in eliminating pain. Athletes are able to return to their normal activities with a rehabilitation program in 3-7 weeks.

Prevention of ITBFS:

By following some steps you can prevent your ITBF syndrome:

1.   Most importantly, always decrease your mileage or take a few days off if you feel pain on the outside of your knee.

2.   Make sure your shoes aren’t worn along the outside of the sole. If they are, replace them.

3.   Run in the middle of the road where it’s flat.

4.   Walk a quarter- to half-mile before you start your runs.

5.   Don’t run on concrete surfaces.

6.   When running on a track, change directions repeatedly.

Some tips for avoid ITBFS:

•      Stretch regularly before and after running. Also stretch on the days you do not run.

•      Get a regular sports massage, in particular to the Iliotibial band and TFL muscle.

•      Increase weekly mileage or training time gradually. As a rule of thumb increase by no more than 10% per week. Listen to your body. You are not training when you are training, you are training when your body recovers and over compensates to the training load.

•      Check feet for biomechanical dysfunction (over pronation). If the feet roll in then this can cause the knee to rotate inwards, stretching and tightening the Iliotibial band.

•      Ensure you have the correct shoes for your feet and running style.

Treatment of ITBFS:

In this case, treatment is applying for reduce pain & inflammation of ITBFS.

Aim of Physiotherapy treatment:

•      Diagnosis the actual cause of ITB friction syndrome.

•      Reduce acute pain and inflammation.

•      Assist the patient with modifying exercise or training regime to reduce pain and prevent recurrence.

•      Normalize joint range of motion of hip.

•      Strengthen of knee, hip and leg muscles

•      Normalize the lower limb muscle lengths.

•      Improve patient’s proprioception, agility and balance.

•      Correction of running and landing technique and function of the patient.

•      The treatment procedure for ITBFS is combined a variety number of treatment options.

Such as;

Rest:

•      Rest is important to allow the inflamed tendon to heal. Continuing to run with ITB syndrome will most likely make it worse. Initially complete rest is a good idea but later activities other than running which do not make the pain worse such as swimming or cycling should be done to maintain fitness.

Cryotherapy:

•      Apply cold therapy or ice to reduce pain and inflammation. Ice should be applied for 10 to 15 minutes every hour until initial pain has gone then later 2 or 3 times a day and / or after exercise is a good idea to ensure the pain does not return.

•      Once the inflammation has gone then potential causes must be addressed such as a tight ITB.

Electrotherapy:

•      Use of electrotherapeutic treatment techniques such as TENS or ultrasound may help reduce pain and inflammation.

Dry-needling:

•      Dry-needling techniques or acupuncture may be beneficial also. Acupuncture is performed by inserting needles of various lengths and diameters into specific points over the body and in this case around the knee joint.

•      The needle is usually inserted, rotated and then either removed immediately or left in place for several minutes. It is thought to be beneficial in reduce chronic or long term pain.

Exercise for ITBS:

Exercises are an important part of any ITB rehab routine. Stretching, strengthening and foam roller exercises all play a part in recovery from ITB syndrome.

IT band stretch at the wall:

•      Setup with your side towards a wall

•      Place supporting foot forward and bend the leg

•      Keep the other leg straight

•      Sink down and don‘t move feet

•      Keep your torso upright or lean away from the wall (to increase stretch)

IT band stretch with chair:

•      Setup with your side towards a chair

•      Place supporting foot forward and bend that leg

•      Keep the other leg straight

•      Sink down and towards chair

•      Keep your torso upright or lean away from chair (to increase stretch)

The deep squat:

•      Feet hip width apart and pointing forward

•      Sit back and keep shins close to vertical

•      If needed: hold something for counter-balance

•      Don‘t let knees collapse inward

•      Keep heels on the floor

•      rest in bottom position (relax for 5 to 10 minutes)

•      Getting up: move from your hips, push them back as far as possible

•      Keep shins close to vertical

•      Don‘t let knees collapse inwards

Stretching exercise:

•      Stretching exercises for the muscles on the outside of the hip in particular are important. The tensor fascia latae muscle is the muscle at the top of the IT band and if this is tight then it can cause the band to be tight increasing the friction on the side of the knee.

Strengthening exercise:

•      Improving the strength of the muscles on the outside of the hip which abduct the leg will help prevent the knee turning inwards when running or walking and therefore help reduce the friction on the ITB tendon at the knee. In particular strengthening exercises for the tensor fascia latae muscle and gluteus medius such as heel drops, clam exercise and hip abduction are important.

Local steroid injection:

•      In acute or prolonged cases a corticosteroid injection into the site of irritation may provide pain relief.

Surgical release:

In some cases surgical release may be needed for releasing tight fascia.

Medication:

•      As a doctor, after assessing we may prescribe anti-inflammatory medication such as NSAID’s e.g. Ibuprofen. This is useful in the early acute stage to reduce pain and inflammation.

Sports massage:

•      A professional Physiotherapist may perform sports massage to help relax and loosen the tissues and use myofascial release techniques which have been shown to be highly effective. Self massage techniques can also be very helpful in correcting excessive ITB tightness.

Home advice for patient:

•      Training modification

•      Errors in training should be identified and corrected.

•      Don’t cross over training or increasing running mileage too quickly.

•      As a general rule a runner should not increase mileage by more than 10% per week.

•      When training starts again avoid too much downhill running. 

•      Do stretches and exercises to strengthen the hip abductors.

That’s end

Thanks