– CAUSES, SYMPTOMS, TREATMENTS & PHYSIOTHERAPY
CO-AUTHORS: MATTHEW CRAIG, PHYSIOTHERAPIST BOUNCEREHAB DIRECTOR & USYD CLINICAL EDUCATOR AUTHOR: NICOLA STIRTON, BOUNCEREHAB PHYSIOTHERAPIST STUDENT – THE UNIVERSITY OF SYDNEY
Iliotibial band friction syndrome (ITBS) is a painful overuse injury usually experienced on the outside of the knee. Its onset is usually gradual over a period of weeks from activity requiring repetitive bending and straightening of the knee such as running &/or cycling. It is said to cause approximately 22% of overuse injuries in runners, whereby symptoms gradually intensify over a period of time due to repetitive movements of the knee. But don’t fear!!! Studies suggest that with a few weeks of conservative physiotherapy management, ITB friction syndrome can be managed very well.
The team at bounceREHAB will have you up and running again in no time!
Before we talk about ITBS, let’s have a quick look at the anatomical structures of the knee…
THE ITB AND TFL MUSCLE:
Your ITB is essentially the tendinous continuation of your Tensor Fascia Lata (TFL) muscle that originates at your hip. The muscle ends at around the same level that
your bottom does. It then merges to form the ITB which travels down the outside of your leg, ending at the lateral shin bone (tibia) and a small portion of fibres anchor on the patella. The image on the right shows you where the TFL starts and where the ITB merges with the TFL.
The TFL muscle helps to stabilise the hip during standing, walking and running by assisting the gluteus minus during hip flexion, abduction and medial rotation. The ITB acts to protect and stabilise the outside of the knee throughout it’s range of motion.
SO WHAT IS ITBS?
Essentially, ITBS is the inflammation of the ITB tendon caused by it rubbing forwards and backwards on the lateral condyle of the knee during running or similar repetitive movements. It is most commonly seen in people who train excessively or increase their training load too rapidly. This increases stress on the body resulting in inadequate time for the tendons to repair and heal naturally.
When the knee is flexed (bent) the ITB sits behind the femoral condyle (a bone protrusion of the femur at the knee joint). As the knee is extended (straightened), the ITB moves forward to eventually sit in front of the femoral condyle when the knee is fully extended.
When this bending and straightening action occurs repetitively, such as in running, the tendon becomes inflamed and begins to cause pain.
WHY DO SOME PEOPLE GET IT AND OTHERS DON’T?
Essentially the chance of developing ITB friction syndrome increases the tighter your ITB gets. When the ITB is under a lot of pressure (stretched/tightened), it rubs more vigorously against the bone on the outside of your knee and hence your chances of developing ITBS increases. Environmental factors such as the type of ground and incline you walk on can cause your ITB to tighten however there are some biomechanical factors that also lead to increased force being placed through your ITB.
(a) Environmental factors:
Normally, your ITB is under its greatest stress during knee flexion of about 20-30 degrees and it is at this bend, pain is at its most severe. Not surprisingly runners tend to feel the greatest amount of pain when their foot first contacts the ground, when their knee is at this angle and the ITB is tightened to stabilise the knee as body weight is put through the joint. Furthermore, running downhill causes the knee to bend further, placing greater pressure through the ITB and hence more pain can be felt. Contrastingly, running fast and sprinting decreases knee bend and therefore pain can be reduced.
(b) Biomechanical factors:
Underlying muscle imbalances such as weakness, tightness, fatigue and ground impact issues can alter running biomechanics and cause your ITB to be placed under greater tension.
The most common causes include:
Poor biomechanics (running technique); particularly inwards rolling knees and hips
Weak hip / gluteal muscles
Weak hip rotators
Weak inner quadriceps VMO/adductors)
Weak core muscles of the trunkTight ITB
Worn out or unsuitable runners
Sudden increase in mileage for training
Excessive hill training (particularly downhill)
Endurance running (training for ½. and full marathons, ultra-marathons)
Let’s use the image below as an example…
Notice in Image A, the pelvis is straight and the ITB is not under any excessive pressure.
In contrast, the pelvis in image B is tilted. This could be due to many of the factors mentioned above. This tilt, stretches the ITB further and hence more pressure is placed through the tendon causing it to run harder against the lateral epicondyle (outer knee bone).
SIGNS AND SYMPTOMS:
The severity of ITB can influence the symptoms a person feels however the most common include:
Sharp/burning pain just above the outer part of the knee
Pain that worsens with continued running or other repetitive activities
Swelling over the outside of the knee.
Pain during early knee bending
Gradual onset of symptoms
HOW IS IT DIAGNOSED?
In order to get a comprehensive understanding of your symptoms and make an accurate diagnosis, the physiotherapists at bounceREHAB will perform a thorough assessment. There are some key factors that they will be looking for that may suggest you do in fact have ITBFS.
Aggravating factors – running downhill and gets worse with activity, usually after a pain-free start.
Area of pain during activities – outside of the knee
Palpation – tenderness on the outside aspect of the knee over the ITB insertion
Active movements – pain is felt during bending and straightening of the knee, especially at around 20 degrees knee flexion.
Tightness – restricted hip adduction due to tight TFL and ITB.
Tight hip flexors may also be present.
Weakness – usually presents in the hip abductors, specifically the gluteus medius.
The following provocative tests may be used:
Ober’s Test Noble test Thomas test
The main treatments are to reduce inflammation, modify activities or rest and to correct the underlying problem. Once pain is reduced, flexibility and strengthening exercises of the muscles around the hip are initiated. It is only when you are pain free, that it is recommended to return to activity. If the ITB has not been fully rehabilitated, there is a risk that the ITBFS will become a more long term, chronic problem. Surgery is available however more commonly used as a ‘last resort’ and not recommended to be effective v’s conservative treatments.
Conservative treatment has a very good outcome for ITBFS. These treatments are performed by a physiotherapist.
In the initial acute phase, pain and anti-inflammatory medication can be taken to reduce the pain and swelling. Corticosteroids can also be injected to the outside of the knee for patients who do not respond well to these medications. During this period, it is also strongly recommended that people should avoid participating in any physical activity that causes pain.
Once pain has been controlled, a stretching program and ROM exercises are prescribed and activity levels can increase gradually. The main muscles that should be targeted at this stage are:
Lumbar Spine flexors/extensors
Myofascial “active release” massage and dry needling “western acupuncture” treatment can also be done by your physiotherapist to abolish any trigger points that may be causing the ITB to tighten or become hypertonic (overactive at rest).
Following this, a progressive exercise program should be started to increase leg strength and resolve muscle imbalances. Compression garments for the ITB are also extremely effective in altering ITB strain by “hugging” the quadricep-hamstrings-ITB lessening the friction of the the distal 1/3 ITB of the lateral femur bone.
In order to return to sport safely, you must be able to perform the stretching and strengthening exercises well and pain free. The usual return to sport occurs 4-6 weeks post injury.
Identifying the cause of the ITB friction syndrome and contributing factors.
Reduce acute pain and inflammation.
Unload your IT band.
Assist you with modifying your exercise or training regime to reduce pain and prevent recurrence.
Normalise joint range of motion of the hip.
Strengthen the knee, hip and leg muscles
Normalise lower limb muscle lengths and core conditioning.
Improve proprioception, agility and balance.
Correct running and landing techniques and function.