Iliotibial band friction syndrome
ART Literature Review:
by Everett Johnson, DC, ART
Iliotibial band friction syndrome, or not?
The season for outdoor events is upon us. People have amped up their training programs to participate in half or full marathons, fun walks, cycling events or triathlons. Many of these people start their training without consulting a healthcare provider or a coach for their specific event. With the availability of online training programs or applications for smartphones, who needs a real-life consultant anyway? Anyone dealing with the sporting community, amateur or professional, knows that wear and tear and poor biomechanics may eventually cause some issues with your training program. Overuse injuries occur after repetitive microtrauma, abnormal biomechanics and inadequate training technique are coupled with inappropriate rest time.
Knee pain is a very common complaint by many runners. Sometimes knee pain is very general and difficult to diagnose without imaging studies. Pain and swelling of the knee can be caused from a plethora of issues. Few conditions of the knee occur with very specific complaints. Here’s a scenario: An amateur runner has made a goal of competing in a half-marathon as part of a weight loss plan. They are about 6 weeks in and have increased mileage. The pain is located on the outside of the knee and is aggravated about half-way through their runs and worse when doing hill workouts. During examination the provider notices tightness along the outer border of the thigh from the hip to the knee and pressure at the outer portion of the knee elicits a negative response from the patient. The scenario described is Iliotibial (IT) band syndrome, and is one of the more common knee injuries in running and cycling athletes occurring in approximately 12% of all running related injuries 1.
The Iliotibial band is the thickened lateral (outside) section of the fascia of the thigh (fascia lata). This double-layer of fascia is also reinforced by thick fibrous bands. It extends from the top of the pelvis down to the outside of the knee where it attaches to the tibia. The IT band has a muscle embedded in it at the top of the thigh called the tensor fascia lata. This muscle tightens the fascia of the thigh and the IT band to provide stability to the hip and knee joints. The IT band also receives the major portion of the tendon from the gluteus maximus at its posterior aspect.
Traditionally, this condition has been described in the literature to occur with repeated flexion of the knee, with the most irritation occurring at about the 30 degrees of flexion mark. The mechanism is described as a friction that takes place between the IT band and the lateral femoral condyle.
A biomechanical model was proposed to explain the pathogenesis of IT band syndrome in distance runners in a 1996 research paper 2. The study looked at the kinematics of nine long distance runners with IT band syndrome. The authors state that friction of the IT band occurs near foot strike and that foot strike occurred at an average knee flexion angle of 21.4 degrees. The authors also found that there was substantial variation in the width of the IT band during cadaver dissection and that this variation may affect if an individual is predisposed to this syndrome.
In 2008 a study was published in the journal Clinical Biomechanics 3 investigating mechanical strain in the IT band as a cause of developing IT band syndrome. The authors examined female runners with IT band syndrome to a control group with no injuries. The authors measured strain on the area, strain rate and how long the runners had the impingement. What they found was that runners had greater amounts of strain through the support period of gait, particularly at mid-support when compared to the control group. They also found that strain rate was greater in the symptomatic group. Strain rate is speed of deformation of the tissues compared to the length of the tissues. The authors concluded that strain rate, rather than magnitude of strain appears to be a causative factor for development of IT band syndrome.
Another major risk factor that has been described for developing IT band syndrome is muscular deficiencies in the hip abductors 4. A study at Stanford University Medical Clinics in June of 2000 looked at strength deficits of the hip abductors in long-distance runners. The authors were trying to determine if correction of those deficits would correlate with the athletes returning to running. They looked at 24 runners with IT band syndrome on one leg, compared hip abductor strength between the injured and non-injured legs and compared that to hip abductor strength in non-injured runners. The runners with injured legs were enrolled in a rehabilitation program designed to strengthen the gluteus medius muscle for 6 weeks. After the 6 week training program 24 of the 26 runners were pain free and returned to running. At a 6 month follow-up none of the runners reported any recurrence of injury to the IT band.
A 2008 study 5 claims that hip abductor weakness is not the cause of IT band syndrome. Strength measurements were taken from ten healthy, asymptomatic runners and ten runners with IT band syndrome. The authors found that muscle strength between the healthy and injured runners were not statistically different in any of the muscles tested. Both groups showed the same differences in strength between the hip abductor and adductor group. The researchers concluded that weak hip abductors did not seem to play a role in the development of IT band syndrome and that strengthening of the abductor group little effect on prevention of IT band syndrome.
A study published in 2006 1 looked at the anatomy of the IT band during flexion and extension of the knee and made some interesting conclusions regarding its anatomy. The researchers used MRI and cadaver dissection to examine the IT band. They found that the IT band was anchored to the region proximal to the lateral epicondyle of the femur by fibrous strands and just deep to it is a highly vascularized and innervated fat pad. The fat pad also had high numbers of a particular type of nerve cell, the Pacinian corpuscle, which is sensitive to pressure and is associated with pain. During the study they observed that the distal portion of the IT band did not slide across the lateral knee, but was drawn closer to the bone. The theory is that the band does not move anterior or posterior since it is anchored to the bone, but different regions of it contract through flexion of the knee joint. When the knee is flexed, stretching of the vastus lateralis muscle (lateral quadriceps) pushes downward on the fat pad under the IT band, increasing the tension at the lateral knee and creating stability.
The authors updated the study in 2007 with an opinion piece published in the Journal of Science in Medicine in Sport 6. The authors suggest that hip abductor weakness on the affected side may be contributory to the condition due to an increase in forces at the joint. Therefore, the pathology of IT band syndrome is proximally based, due to dysfunction of the abductor group of the affected leg. The authors also state that due to the IT band being firmly attached to the lateral femoral condyle through fibrous bands, it is near impossible to achieve a good stretch of the band. The rationale is since the IT band is simply a doubled layer of the fascia of the thigh, stretching would have to occur not only in the band that is firmly adhered to the femur, but also to the entire fascia lata and the lateral intermuscular septum.
Treatment options described in the research literature are all fairly standard. An article in the Clinical Journal of Sports Medicine published in 2006 7 describes common practical management of IT band syndrome. During the acute phase it is recommended that treatment focus on modification of activity, ice, anti-inflammatory medication or injections for severe swelling or pain. The subacute phase should focus on stretching and soft tissue therapy to release any myofascial restrictions. Recovery focuses on exercises to rehabilitate the hip abductors and the integration of hip movement patterns. Running exercises are suggested every other day with no hill training.
A study published in the journal Sports Medicine in 2005 8 also suggests activity modification during the acute phase of injury, eliminating myofascial restrictions during the subacute phase and then proceeding with a rehabilitation program focused on strength and muscular re-education of the hip abductors. This author states that the exercises should emphasize eccentric contractions of the muscles and incorporate triplanar motions and integrated movement patterns.
In conclusion, the anatomical evidence based on the 2006 study by Fairclough 1 showed us that the IT band does not move or cause friction at the lateral knee, but causes compression of the innervated structures around the knee. The increased compression is due to increased forces placed on the lateral knee when the hip abductors are weakened and not functioning properly during gait. We know that muscular adhesions cause muscle weakness and tightening, which is true in the case of the muscles of the hip joint implicated in IT band syndrome. It is the suggestion of this author that during the acute phase we should take a different approach. The previous studies mention following the RICE approach. I think this is true for the area that is inflamed (ie. lateral knee), but we should start releasing myofascial adhesions in the muscles of the hip to increase function of those muscles. Active Release Techniques (ART) provides a way to increase tissue mobility, breakdown adhesions and return the muscles to a normal functional unit so that when rehabilitation is started the muscle will be more receptive. This equals quicker return to training for that event and very happy patient.
1. Fairclough J, et.al. (2006) The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J. Anat 208, pp 309-316.
2. Orchard JW, Fricker PA, Abdu AT, Mason BR. (1996) Biomechanics of the iliotibial band friction syndrome in runners. Am J Sports Med 24,(3), pp 375-379.
3. Hamill J, Miller R, Noehren B, Davis I. (2008) A prospective study of iliotibial band strain in runners. Clin Biomech 23(8) pp1018-1025.
4. Fredericson M, Cookingham CL, et.al. (2000) Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 10(3) pp169-175.
5. Grau S, Krauss I, et.al. (2008) Hip abductor weakness is not the cause for iliotibial band syndrome. Int J Sports Med. 29(7) pp 579-583.
6. Fairclough J, et.al. (2007) Is iliotibial band syndrome really a friction syndrome. Journal of Science and Medicine in Sport. 10 pp 74-76.
7. Fredericson M, Weir A (2006) Practical management of iliotibial band friction syndrome in runners. Clin J Sport Med. 16(3) pp 261-268.
8. Fredericson M, Wolf C (2005) Iliotibial band syndrome in runners: innovations in treatment. Spots Med. 35(5) pp 451-459.