Iliotibial Band Syndrome: Soft Tissue and Biomechanical Factors in Evaluation and Treatment

Home , Iliotibial band syndrome, Iliotibial tract, Running injuries

Clinical Review: Current Concepts

Robert L. Baker, BSPT, MBA, Richard B. Souza, PhD, PT, Michael Fredericson, MD

Muscle performance factors and altered loading mechanics have been linked to a variety of lower extremity musculoskeletal disorders. In this article, biomechanical risk factors associated with iliotibial band syndrome (ITBS) are described, and a strategy for incorporating these factors into the clinical evaluation of and treatment for that disorder is presented. Abnormal movement patterns in runners and cyclists with ITBS are discussed, and the pathophysiological characteristics of this syndrome are considered in light of prior and current studies in anatomy. Differential diagnoses and the use of imaging, medications, and injections in the treatment of ITBS are reviewed. The roles of hip muscle strength, kinematics, and kinetics are detailed, and the assessment and treatment of muscle performance factors are discussed, with emphasis on identifying and treating movement dysfunction. Various stages of rehabilitation, including strengthening progressions to reduce soft-tissue injury, are described in detail. ITBS is an extremely common orthopedic condition that presents with consistent dysfunctional patterns in muscle performance and movement deviation. Through careful assessment of lower quarter function, the clinician can properly identify individuals and initiate treatment. PM R 2011;3:550-561

INTRODUCTION Iliotibial band syndrome (ITBS) is the leading cause of lateral knee pain in runners and accounts for 15% of overuse injuries in cyclists [1-5]. While balancing the need to promote fitness and the associated risks of repetitive-motion injuries such as ITBS, physicians and other rehabilitation professionals have searched for methods of identifying contributing factors for overuse injuries as well as treatments that restore function and enable patients to maintain their exercise activities. The first detailed case on ITBS was published by Renne [6] in 1975. The subjects studied were military recruits whose running and training activities had increased rapidly. Hall- marks of ITBS were pain on weight bearing at 30° of knee flexion and the exacerbation of pain after having run more than 2 miles or having hiked more than 10 miles. Lateral knee pain at the femoral epicondyle is a key finding in patients with ITBS [6-8]. R.L.B. Emeryville Sports Physical Therapy, Noble [9] analyzed 100 patients with ITBS and developed the Noble compression test, in 2322 Powell Street, Emeryville, CA 94608. Address correspondence to R.L.B; e-mail: which compression over the lateral epicondyle of the femur at 30° of knee flexion elicits pain [email protected] reproduction. This test is now commonly used to diagnose ITBS. Orchard et al [10] Disclosure: nothing to disclose described ITBS in runners as an impingement zone related to the time period just after heel R.B.S. Department of Physical Therapy and strike as the knee approaches 30° of flexion. The investigators described this as the Rehabilitation Science, Department of Radiol- deceleration phase, which suggests that impingement occurs during eccentric loading of the ogy and Biomedical Imaging, University of California, San Francisco, CA iliotibial band during the weight-acceptance phase of running. Disclosure: nothing to disclose M.F. Division of Physical Medicine and Re- habilitation, Department of Orthopaedic Sur- ANATOMIC CONSIDERATIONS gery, Stanford University School of Medicine, Stanford, CA The iliotibial band is a fascial structure composed of dense connective tissue that assists Disclosure: nothing to disclose stance stability and is capable of resisting large varus torques at the knee [7,11,12]. Disclosure Key can be found on the Table of Proximally, the iliotibial band provides an insertion for the tensor fascia lata and gluteus Contents and at www.pmrjournal.org maximus muscles [13]. Based on dissections of 1 orangutan, 3 chimpanzees, 1 gorilla, 1 Submitted for publication September 16, bear, and other 4-legged animals, Kaplan [13] concluded that, although all quadruped 2010; accepted January 4, 2011.

PM&R © 2011 by the American Academy of Physical Medicine and Rehabilitation 550 1934-1482/11/$36.00 Vol. 3, 550-561, June 2011 Printed in U.S.A. DOI: 10.1016/j.pmrj.2011.01.002 PM&R Vol. 3, Iss. 6, 2011 551

patellar retinaculum, patella (by way of epicondylopatellar ligament and patellar retinaculum), and patellar tendon [13,14,16]. Collectively, these anterior and lateral attachments form a horseshoe pattern or inverted U shape well positioned for anterolateral support to the knee [15,19,20]. The site of injury is often associated with the insertion at the lateral epicondyle but interrelated with the forces created by the various attachments above and below the lateral epicondyle (Figure 1). Fairclough et al [14] described a mechanism of compression of the iliotibial band against the lateral epicondyle that occurs at 30° of knee flexion. Their anatomic description included the observation that compression of the adipose tissue at the lateral epicondyle of the femur caused pain and inflammation but that no anterior–posterior movement of the band moving over the epicondyle took place, simply an approximation of the iliotibial band into the lateral epicondyle as the knee internally rotated during flexion from an extended position. The investigators present an anatomical viewpoint that contradicts the commonly held theory of a friction syndrome [14]. Fairclough et al [14] described friction as an unlikely cause of ITBS, because the band inserts deeply and strongly into the femur. The functional anatomy may be relevant because a fat pad and pacinian corpuscle compression mechanism may have different mechanorecep- tor implications compared with a friction syndrome, although inflammation remains the primary concern.

Figure 1. The iliotibial band and site of injury at lateral epicondyle of the femur. INTRINSIC CONTRIBUTING FACTORS Biomechanics of the Hip, Knee, and Ankle animals have tensor fascia latae or gluteus maximus muscles, Ferber et al [21] attributed iliotibial band strain in female they do not all have an iliotibial band. The investigator then runners to a greater peak hip adduction angle and greater suggests that the iliotibial band is an independent stabilizer of peak knee internal rotation angle compared with those in the lateral knee joint, essential for erect posture. The iliotibial controls. The investigators used a retrospective design and band has 2 significant attachments, including the lateral control group comparison. The theory presented was in- epicondyle and the Gerdy tubercle (Figure 1) [13,14]. The creased tensile stress at the hip in the frontal plane and first iliotibial band attachment is into the distal femur at the internal rotation stress at the knee. Interestingly, in this upper edge of the lateral epicondyle [15]. The histologic study, patients with ITBS exhibited femoral external rotation makeup is consistent with tendon and has a layer of adipose versus internal rotation when compared with control sub- tissue underneath the iliotibial band attachment area [14,16]. jects, a factor that increased knee internal rotation. The adipose tissue contains pacinian corpuscles, is highly In 2007, Noehren et al [22] published a prospective study vascular, and may be the site of the inflammation that causes of female runners that analyzed ITBS and biomechanical pain during compression. The second attachment of the factors, including hip adduction, knee internal rotation, and iliotibial band is the insertion into the Gerdy tubercle of rear foot eversion angles, and related hip, knee, and ankle the tibia and serves as a ligament in structure and function. moments. The investigators performed bilateral, 3-dimen- The Gerdy tubercle attachment is tensed during tibia internal sional, lower extremity kinematic and kinetic analysis with rotation as the knee flexes during the weight-acceptance running. The subjects were followed up for injury findings phase of gait [14,16,17]. Internal tibial rotation explains the through 2 years by e-mail communication. Findings for the occasional connection between toeing in and iliotibial band ITBS group versus the control group included the following: strain [4,18]. (1) greater peak hip adduction, (2) greater peak knee internal The iliotibial band has many other distal attachments, rotation angle, (3) lower tibial internal rotation by 2.2° (not which include the biceps femoris, vastus lateralis, lateral significant), and (4) femoral external rotation. On visual 552 Baker et al ILIOTIBIAL BAND SYNDROME

Figure 2. (A) Normal alignment. (B) Trendelenburg sign. (C) Compensated Trendelenburg sign. Reprinted with permission of the Sports and Orthopedic Sections of the American Physical Therapy Association and Chris Powers, PhD, PT. Powers C. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther 2010;40:42-49 [27]. inspection, the investigators noted that the subjects with anterior superior iliac spine to medial malleolus, reported ITBS landed in greater hip adduction and knee internal in 10%. McNicol et al [26] also reported on 52 cases of ITBS rotation. Noehren et al [22] and Ferber et al [21] support the in runners, including 34 men and 18 women with ITBS. The theory of frontal and transverse plane factors in female run- investigators reported that 55% had mild-to-severe knee ners, specifically, excessive hip adduction and knee internal varus, and 8% had mild knee valgus. These studies suggest rotation. Further study is needed to explain why these run- that clinical management of ITBS may involve training meth- ners exhibited greater hip adduction, knee internal rotation, ods to control frontal plane dynamics at the knee, in addition and femoral external rotation. In addition, male runners need to assessing and treating transverse plane issues. further assessment in similar research models. Weight-bear- One way to theoretically visualize the relationship being magnetic resonance imaging and dual fluoroscopic imag- tween the hip and knee frontal plane relationships involves ing may be useful to further assess femoral rotation in male the use of ground reaction force diagrams. During normal and female runners with and without ITBS, specifically single-limb stance as described by Powers [27], the ground aimed at evaluating the role of transverse plane contributing reaction force vector may pass medial to the knee joint and factors of the hip [23-25]. produce a varus torque at the knee (Figure 2A). However, Hamill et al [12] modeled iliotibial band strain rate with with excessive hip adduction during a single-limb stance and software for interactive musculoskeletal modeling (SIMM Trendelenburg sign, the ground reaction force vector may 4.0; Motion Analysis Corporation, Santa Rosa, CA). This pass more medial, with a larger perpendicular distance to the prospective study of female runners compared iliotibial band knee joint (Figure 2B). The result is an increased varus torque strain (calculated as the change in length during running at the knee, along with an elongated lateral hip musculature, divided by the resting length), strain rate (calculated as the both of which place increased stress on the iliotibial band change in strain divided by the change in time), and duration [27,28]. The third possible disturbance at the knee is a valgus of impingement in 17 patients with ITBS and 17 age-matched stress and ground reaction force vector lateral to the knee, controls. The entire stance was measured, with a focus on combined with an increased hip adduction, a compensated touch-down and peak knee flexion. Although strain was Trendelenburg sign (Figure 2C). increased versus that in the control, only strain rate was Abnormal mechanics at the foot and the tibia may play a statistically significant between the groups. The investigators role in the development of ITBS given the anatomic connec- suggested that strain rate is a factor in the development of tion of the iliotibial band to the tibia and the interrelationship ITBS. of the foot and the tibia. Noehren et al [22] analyzed biome- Taunton et al [5] used a retrospective design to analyze chanical factors in the hip, knee, and rear foot in female data on 2002 running injuries, including 63 men and 105 runners who go on to develop ITBS, and, although hip women with ITBS. Varus knee alignment was reported in adduction and knee internal rotation were the primary find- 33%, and valgus alignment was reported in 15%. Leg-length ings in this cohort, these investigators were able to identify a discrepancy, defined as a greater than 0.5-cm difference in subset of 4 participants who exhibited excessive calcaneal PM&R Vol. 3, Iss. 6, 2011 553

eversion and tibial internal rotation. In contrast, Messier et al [29] performed a cross-sectional lower extremity kinematic study on male and female patients with ITBS and reported no statistically significant differences in rear foot eversion when compared with a control group. Miller et al [30] analyzed 16 runners, 8 with history of ITBS and 8 age-matched controls, in an exhaustive run. At the end of the run, the patients in the ITBS cases exhibited greater maximum foot inversion (3.3° ITBS and Ϫ9.5° control), maximum knee flexion at heel strike (43.8° ITBS and 36.5° control), and maximum knee internal rotation velocity (16.4°/s ITBS and 10.3°/s control). Further research is needed to better understand the possible connection between the foot mechanics and increased knee internal rotation velocity. Leg-length discrepancies have been reported as a factor in developing ITBS. McNicol et al [26] studied 52 cases of ITBS in runners and reported that 13% had leg-length discrepancies, and, in all cases, that the side of injury corresponded with the longer leg. However, Messier et al [29] evaluated a variety of intrinsic and extrinsic factors in 56 patients with ITBS and 70 controls, reporting leg-length discrepancies Figure 3. Muscle performance factors include a broad set of consistent between the control group and the injured group. muscle competencies, including response to the kinetic chain above and below. Taken together in a clinical perspective, ITBS and foot and ankle factors suggest a possible subset of cases in runners who have abnormal foot and ankle biomechanics, including excessive calcaneal eversion and tibial internal rotation along shortened and strong. The clinical finding is increased hip with leg-length discrepancy. flexion in stance, along with a tendency for increased hip internal rotation [3,32-37]. In contrast, the gluteus maximus and gluteus medius are phasic muscles with the tendency to Muscle Performance become lengthened and weak [36,37]. Subsequently, the taut and relatively stronger tensor fascia lata may dominate Messier et al [29] reported generalized strength and endur- the weaker gluteus medius posterior and gluteus maximus, ance considerations as a possible etiologic factor in male and and may result in a postural pattern, including a Trendelen- female participants with ITBS. Fredericson et al [3] reported burg sign (Figure 2B) or compensated Trendelenburg sign significant hip abductor strength deficits in patients with (Figure 2C) [27,38]. These compensations during walking or ITBS compared with noninjured control runners, and good running may result in poor control of the hip and femur success in these injured patients after a 6-week strengthening during stance and may lead to excessive hip adduction and program focused on strengthening the gluteus medius mus- knee varus or valgus. The Janda-based analysis of muscle cle. Miller et al [30] reported that, on average, patients in the imbalance provides a theoretical construct to understand and ITBS cases were tighter in the iliotibial band than control treat some of the factors related to ITBS, specifically, runners when the Ober test was used. The investigators also strengthening of the gluteus medius and gluteus maximus reported an increased maximum knee internal rotation ve- muscles to better control hip adduction and knee varus and locity in patients in the ITBS cases near exhaustion, which valgus. suggests fatigue-related factors. In a separate study that evaluated runners during an exhaustive run, Miller et al [31] EXTRINSIC CONTRIBUTING FACTORS suggested that runners with a history of ITBS use abnormal segmental coordination patterns. The scope of muscle per- Extrinsic factors are related to training methods as well as formance factors in ITBS includes strength, endurance, flex- running shoes or cycle fit, and have been researched and ibility. and segmental coordination (Figure 3). reported in connection with ITBS [2,4,10,29]. Key elements The Janda approach to muscle imbalance provides a the- in such research include repetitions at about 30° of knee oretical model that assists in the analysis of muscle strength flexion (the impingement zone) in a closed-chain and and flexibility as it relates to excessive hip adduction and weight-bearing position. Farrell et al [2] analyzed cycling knee varus or valgus. The tensor fascia lata is classified by kinematic and kinetic data to reported values for running, Janda as a postural muscle with the tendency to become with a focus on iliotibial band impingement at the knee. Ten 554 Baker et al ILIOTIBIAL BAND SYNDROME

noninjured cyclists were analyzed with motion analysis and Taunton et al [5] reported on 168 cases of ITBS with a synchronized foot-pedal forces. Findings included the fol- distribution 38% men, 62% women, average weekly hours of lowing: (1) lower pedal reaction force at 17%-19% versus running 4.9, training years 7.3, body mass index of 23.7 for ground reaction force in runners, and (2) shorter impinge- men and 21.2 for women, and age 31.1 years. Only age ment zone contact time, calculated at 38 ms in cyclists versus younger than 34 years in men was a significant factor among 75 ms in runners. However, the investigators discussed the these variables. ITBS was associated with pain after a run that issue of repetitive stress in a typical workout, commenting restricted the ability to run. McNicol et al [26] reported 52 that cycling results in more repetitions (ie, 6600 repetitions cases of ITBs; 42% were found to be related to training errors, during a 1.25-hour ride versus 4800 repetitions during a such as rapid commencement (2 cases), sudden hill exposure 10-km run). Interestingly, Farrell et al [2] described a theo- (1 case), single severe session (12 cases), rapid increase retical mechanism of stress to the iliotibial band in cyclists in volume of training (7 cases), and footwear and surface issues which the shorter leg, when fixed to the pedal, is over- (4 cases). Similarly, Messier et al [29] studied 48 cases of stretched laterally and functions in less knee flexion, thereby ITBS; compared with 70 controls and reported ITBS cases, increasing the time spend in the impingement zone. Whether the patients had increased training mileage and less experi- running or cycling, the factors of impingement time and ence. In summary, the subjective examination in cases of intensity of loading are important. ITBS has the defining characteristics of lateral knee pain with Training factors, including rapid increases in mileage and repetitive knee activity usually in a weight-bearing position hill training, can lead to iliotibial band injury [2,29]. Orchard and associated overtraining issues. et al [10] suggested that increased impingement zone impact Objectively, the Noble compression test may be used to time during both downhill and slow running leads to ITBS provocate symptoms by compressing the iliotibial band at the and sprinting may result in relatively less impact time be- lateral epicondyle with 30° knee flexion [9]. The patient is cause of greater knee flexion beyond the impingement zone. positioned with the knee at 90° flexion, and compression is This particular theory was not supported by Miller et al [30], applied just proximal to the lateral epicondyle as the knee who found, during an exhaustive run, increased knee flexion is extended toward full extension. The 30° flexion is the at heel strike in runners with a history of ITBS. Our review impingement zone specific to the iliotibial band and lateral did not find experimental studies that evaluated the effect of femoral epicondyle as described in cadaver studies by both sprinting on iliotibial band strain or impingement, although Orchard et al [10] and Fairclough et al [14]. Differentiating the topic seems relevant for future research. Messier et al [29] related structures uses this impingement zone concept as reported that less experienced runners with rapid changes in well as lack of other objective test findings for injury to the mileage were at risk for ITBS, but hypothesized that intrinsic lateral meniscus, lateral retinaculum, popliteus and biceps factors, including strength deficits, were necessary for extrin- femoris tendons, patellofemoral joint, and lateral collateral sic factors to cause symptoms. The investigators also reported ligament. Although not frequently used for diagnosis, Ekman increased cross-training habits (ie, swimming and cycling) in et al [40] used magnetic resonance imaging to evaluate 7 runners with ITBS versus the control group. patients with ITBS and 10 age- and gender-matched controls. The investigators reported thickening of the iliotibial band CLINICAL EXAMINATION over the lateral femoral condyle (5.49 mm ITBS and 2.52 mm control; P Ͻ .05) and fluid deep to the iliotibial band at the Sutker et al [39] evaluated 1030 runners with lower extrem- lateral epicondyle in 5 of 7 cases. ity complaints and diagnosed 48 cases of ITBS. Subjectively, the patients described lateral knee pain associated with repetitive loading in a weight-bearing position (ie, running and Clinical Assessment of Flexibility stairs). Functionally, the runners were able to perform activities such as a hop and squat without pain. This contrasts Flexibility of the lateral hip musculature has routinely been with the cases presented by Renne [6], in which military tested as a factor in ITBS [33]. The rationale in testing and recruits in daily training exhibited a limp and straight leg gait treating is related to muscle performance factors (Figure 3) pattern. Renne [6] also noted that the symptoms were aggra- and biomechanical factors, given the issue of iliotibial band vated by running more than 2 miles and hiking more than10 compression at the lateral epicondyle of the femur. Messier et miles. Sutker et al [39] confirmed the diagnosis of ITBS by the al [29] analyzed stretching habits in 56 runners with ITBS history and tenderness localized at the lateral epicondyle of and 70 controls and found that both groups stretched, but the femur or less commonly at the Gerdy tubercle. Concur- differences were not established. Fredericson et al [41] ana- rently, the patients did not have symptoms at the lateral joint lyzed the effectiveness of 3 iliotibial band stretches, in 5 male line or popliteal tendon, and did not have signs of intra- elite distance runners, and found significant changes in the articular disorders. iliotibial band length in all 3 types of stretching. The investi- The subjective examination includes the clinical applica- gators proposed benefits to stretching such as reducing ili- tion of previous information on factors associated with ITBS. otibial band tension by hip abductor muscle inhibition and PM&R Vol. 3, Iss. 6, 2011 555

Clinical Assessment of Strength The functionally weak gluteus medius and gluteus maximus reduces eccentric control of the hip and femur in stance [33,34]. To detect hip muscle imbalance between the tensor fascia lata and the gluteus medius and maximus, the clinician can perform surface electromyography (EMG) to observe for muscle substitution: (1) tensor fascia lata may substitute for the posterior fibers of the gluteus medius, and (2) hamstring may substitute for the gluteus maximus as described by Kendall et al [38]. Functional tests offer insight into muscle substitutions on a regional basis, such as trunk and lower- extremity strength, including signs of excessive femur internal rotation, ipsilateral hip adduction, and contralateral hip drop during a step-down test or Trendelenburg test (Figures 5 and 6) [37,45,46]. The utility of the standing functional tests is debated based on minimal detectable change and Figure 4. The Ober test. whether or not weakness exists in the hip musculature (ie, gluteal muscles) or core stabilizers (ie, internal obliques, transverse abdominus, multifidus) [37,46]. However, the improvement in fascial adhesions and myofascial trigger functional tests may identify muscle performance factors that points. a patient can see firsthand, a powerful motivator in treatment The Ober test is commonly performed to assess iliotibial compliance. The gluteus maximus muscle strength should band length. Gose and Schweizer [42] describe the Ober test also be tested, given its role of hip stabilizer in the frontal as follows: (1) position the patient on side, lying with the plane [47] and ability to influence femur rotation (ie, con- centric femur external rotation and eccentric femur internal tested leg up; (2) with the knee flexed to 90° and the pelvis rotation) [36,38,47]. Testing the gluteus maximus can be stabilized, position the hip in a flexed and abducted posture; performed with the patient in the prone position with the (3) extend the hip to achieve adequate extension so that the knee flexed to 90° and the hip in neutral rotation by using a iliotibial band is over or behind the greater trochanter; and manual muscle test or hand-held dynamometer against the (4) allow the thigh to fall into adduction (Figure 4). The iliotibial band restriction is designated as follows: (a) minimal (adducted past the horizontal but not fully to the table), (b) moderate (adducted to the horizontal), and (c) maximal (patient is unable to adduct to the horizontal). Because the Ober test requires adequate hip extension (approximately to a neutral hip with knee flexed 90°), the use of the modified Thomas test is also recommended. Clapis et al [43] evaluated 42 noninjured subjects in the modified Thomas test by using an inclinometer and goniometer to measure joint ranges. The subjects sat close to the edge of the table, supported the left thigh to the chest, and rolled back to the supine position. The right leg was positioned to hang off the table. To standardize the measurements, the lumbar lordosis was flattened and palpated in that position during the test. The tested hip was placed in neutral hip abduction– adduction. A goniometer was aligned proximally with the midline of pelvis and distally with the midline of the femur. Interclass correlation (ICC) measurements by goniometer were 0.92 and by inclinometer were 0.89. Harvey [44] analyzed the modified Thomas test in 117 elite athletes in tennis, running, rowing, and basketball. ICCs were 0.91-0.94, and findings were as follows: (1) psoas averaged Ϫ11.9° (below Figure 5. Normal step-down test on a 6-inch (15.24-cm) box the horizontal), (2) quadriceps was 52.5°, and (3) tensor demonstrates level hips at 10 repetitions. Performed on 8-inch (20.32-cm) box if normal at 6-inch (15.24-cm) height. fascia lata–iliotibial band averaged 15.6° abduction. 556 Baker et al ILIOTIBIAL BAND SYNDROME

days and anti-inflammatory–analgesic after 14 days. If there is significant swelling or tenderness at the lateral epicondyle resistant to oral anti-inflammatory medication and physical therapy modalities, then a corticosteroid injection at the lateral epicondyle of the femur should be considered early in the treatment course [51]. Patient education is critical to success. Extrinsic factors have been described, including excessive weekly mileage, overtraining, hill training, and other activities that place the iliotibial band in the impingement zone, for example, swimming [5,26,29]. Sutker et al [39] reported on 48 cases of ITBS and found a trend in running 20-40 miles per week for more than 1 year. McNicol et al [26] reported on 52 cases of ITBS in athletes and found that 26 cases involved training-related issues. Exercise approaches for ITBS have thus far supported strengthening of the gluteus medius (ie, side-lying hip abduction and hip hiking) [3,52]. Approaches to hip strengthening are rapidly increasing, especially targeted to the gluteus medius and maximus [53,54]. Some experts (ie, Fredericson, Figure 6. Abnormal step-down test exhibits a contralateral hip Geraci) have recommended innovative closed chain ap- drop during the step down. proaches to treating ITBS, such as triplanar lunge and squat exercises [33,34]. EMG activation studies of the gluteal muscles provide lower portion of the posterior femur [36,38,48]. The patient direction to therapeutic exercise programs. Distefano et al should be able to fully resist without a break and should have [55] analyzed mean EMG as a percentage of maximal volun- symmetrical strength side to side. The deep external rotator muscles are important stabilizers of the hip, including the obturator internus and externus, gemellus superior and infe- Table 1. Phases of rehabilitation recommended by Frederic- son and Wolf [33] rior, quadratus femoris, and piriformis [49]. The muscle test position described by Janda [36] is supine, test leg off the Acute Phase table and nontest leg flexed at the hip and the knee, with the Goal: Reduce inflammation of the iliotibial band at the foot on the table, fixate below the distal femur, and resistance lateral femoral epicondyle (Figure 1) 1. Control extrinsic factors, such as rest from running and applied above the medial malleolus as the patient moves cycling through full range. 2. In severe cases patients should avoid any activities with repetitive knee flexion-extension and swim using only their arms and a pool buoy Treatment 3. The use of concurrent therapies is advised (ie, ice, Fredericson and Wolf [33] developed a useful format for phonophoresis, or iontophoresis) [1,50] 4. Oral, nonsteroidal anti-inflammatory medication is stages of treatment (Table 1): acute, subacute, and recovery recommended strengthening. Treatment of ITBS is driven by the pathophys- 5. Corticosteroid injection, if no response to the above iology of inflammation and the biomechanics of iliotibial methods band strain [32,33]. The path to recovery involves correction 6. Up to 2 pain-free weeks before return to running or of contributing factors such as weakness of the gluteus me- cycling in a graded progression Subacute Phase dius and excessive hip adduction and knee internal rotation, Goal: Achieve flexibility in the iliotibial band as a foundation leg-length discrepancies, and excessive knee varus or valgus to strength training without pain strain. 1. Iliotibial band stretching (Figure 7) Given the finding of soft-tissue thickening and fluid under 2. Soft tissue mobilization to reduce myofascial adhesions the iliotibial band at the lateral epicondyle [8,40], the early Recovery Strengthening Phase Goal: Strengthen the gluteus medius muscle including use of anti-inflammatory medications, soft-tissue mobiliza- multiplanar closed chain exercises tion, and stretching are advised [7,8,33,39,50]. Ellis et al [1] 1. Exercises should be pain free performed a systematic review of conservative treatments for 2. Repetitions and sets of exercises are 8-15 repetitions and ITBS. By using the Physiotherapy Evidence Database criteria, 2-3 sets corticosteroid injection and nonsteroidal anti-inflammatory 3. Recommend the exercises of sidelying hip abduction, single leg activities, pelvic drops, and multiplanar lunges medications were moderately supported within the first 14 PM&R Vol. 3, Iss. 6, 2011 557

tary isometric contraction in 21 healthy subjects during a variety of open and closed chain exercises for the gluteus medius and gluteus maximus. The only resistance was segmental body weight, gravity, and resistance bands. The investigators were careful to use positions that promoted a gluteal recruitment pattern, such as a vertical tibia with lunging and forward trunk by hip ﬂexion with squat activity. The list of compared exercises included side-lying hip abduction, clam shell, lateral band walks, single-limb squat, single- limb dead lift, multiplanar lunges, and multiplanar hops. The

ICC3,1 were 0.85-0.98 for gluteus maximus and 0.93-0.98 gluteus medius except for multiplanar hops. The investigators proposed that 60% or greater normalized EMG as a percentage of maximal voluntary isometric contraction was the requirement for a strengthening exercise [55,56]. The gluteus medius averaged 61% lateral band walk, 64% single- limb squat, and 81% side-lying hip abduction. The gluteus Figure 8. Resisted clam shell is a beginning-level exercise for maximus averaged 59% in single-limb dead lift and single- gluteal muscle recruitment. limb squat. The side-lying clam shell did not use a resistance band and achieved 38%-40% activation in the gluteus medius. This study supported the use of functional-based exer- investigators demonstrated that the 25-lb (0.91-kg) lift with cises and open chain resistance exercises to strengthen the knees flexed and tibias forward generated a strong quadri- gluteal muscles from the viewpoint of EMG patterns. ceps EMG and minimal gluteus maximus EMG. The straight The positioning of the trunk and degree of knee flexion knee and trunk flexed 25-lb (0.91-kg) lift produced minimal may change the EMG in the gluteus medius and maximus. quadriceps and gluteus maximus EMG but strong hamstring Fischer and Houtz [57] analyzed a floor-to-waist lift of 25 lb EMG. The sacrospinalis muscle was active in both lifts. When (0.91 kg) with the knees straight and the trunk and hips compared with the EMG and exercise activities in the Diste- flexed versus hips and knees flexed (ie, forward tibias) in 11 fano study [55], the differences may be related to the position healthy women, aged 15-23 years. EMG activity was mea- of the tibia, because Fischer and Houtz [57] allowed a much sured in the gluteus maximus, sacrospinalis, medial and greater forward position of the tibia. In addition, Fischer and lateral hamstrings, and quadriceps femoris muscles. The Houtz [57] used a bilateral leg activity in the sagittal plane, whereas Distefano et al [55] chose more unilateral limb activities and multiplanar tasks. The clinical significance is that the biomechanical details in functional exercise are critical to strengthening the gluteal muscles (ie, single leg, multiplanar, vertical tibia). Noehren et al [58] used real-time visual biofeedback to successfully train 10 female subjects with anterior knee pain and a diagnosis of patellofemoral pain syndrome. Inclusion also required excessive hip adduction on motion analysis. The hip adduction angle was displayed onto a monitor placed in front of the treadmill. Instructions were to contract the gluteal muscles and run with the knees pointed straight ahead, and to maintain a level pelvis. The sessions progressed from 15-30 minutes over 8 sessions, and the visual feedback was faded in sessions 5-8. The participants were not allowed to run outside this training. The program involved faded feedback over 8 treatment sessions (4 times per week for 2 weeks). The result was a 23% decrease in ipsilateral hip adduction during running that was maintained at 1-month follow-up. Although patellofemoral pain cases with other biomechanical issues such as increased hip internal rotation, the relevance to ITBS is the possible use of faded feedback in Figure 7. Iliotibial band stretch in standing [41]. running to control excessive hip adduction. Similarly, Barrios 558 Baker et al ILIOTIBIAL BAND SYNDROME

Figure 9. Resisted hip abduction and bridge is a beginning- Figure 11. Resisted hip extension, external rotation, and ab- level exercise that facilitates gluteal recruitment. duction comprise a beginning-level exercise that facilitates gluteus maximus and gluteus medius recruitment. et al [59] studied visual faded feedback to reduce excessive cognitive component that allows biomechanical improve- knee external adduction moment during treadmill walking in ments in 8 sessions. 8 noninjured participants with varus knee alignment, aged The exercises that have been researched speciﬁc to ITBS 18-35 years. The verbal cues to the participants were “bring have included side-lying hip abduction and pelvic drops at 3 the thighs closer” and “walk with your knees closer together” sets and 30 repetitions and 6 weeks of treatment [3]. The while maintaining a normal foot progression angle. The side-lying hip abduction exhibited strong EMG activation in training was 8 sessions with faded feedback in sessions 5 the study by Distefano et al [55], and single leg functional through 8. Statistical signiﬁcance was reported before to after activity demonstrated higher EMG activation versus double- training for knee external adduction moment, on average leg closed chain exercise. Furthermore, as stated previously, 20% reduction (P ϭ .027). Although performed on noninjured participants with varus alignment, this particular approach may assist patients in ITBS cases with excessive knee varus. In practice, real-time visual feedback has a strong

Figure 10. Resisted hip extension and knee ﬂexion in quadru- Figure 12. Contralateral pelvic drop (starting position) is an ped is a beginning-level exercise that facilitates gluteus max- intermediate-level exercise used successfully to strengthen hip imus recruitment. abductors in runners with ITBS [3]. PM&R Vol. 3, Iss. 6, 2011 559

Figure 13. Resisted squat is an intermediate exercise that uses Figure 15. Resisted squat with a single-leg emphasis is a more hip abduction and vertical tibial alignment to facilitate gluteus vigorous exercise to facilitate single-leg control with the gluteal maximus control. muscles, facilitated by hip abduction and external rotation. the study by Distefano et al [55] used several other useful stretch, side-lying hip abduction and pelvic drops, and a modiﬁcations in functional exercises that seemed to facilitate progression of technique-driven closed chain exercises, as gluteal recruitment: (1) more vertical tibia, (2) forward trunk illustrated in Figures 7-17 (ie, vertical tibia and trunk ﬂexion lean, (3) resistance band with side walks, (4) multiplanar from the hips). The bilateral closed chain exercises are rela- activity, and (5) good control of trunk position. The clam tively low vigor and were used early in the recovery to shell exercise without the resistance band, and the lunge promote technique in squats, whereas the single-leg activities patterns without use of added weight, demonstrated gluteal are of higher vigor and intended for strengthening the gluteal muscle EMG less than 60%, therefore, we recommend use of muscles. resistance with these exercises. Based on these EMG studies [55,57], research on exercise RESUMING PARTICIPATION IN SPORTS and ITBS [3,52], and recent case studies focused on strengthening the gluteal muscles [53,54], our recommended pro- Participation in sports is dependent upon being able to gressions of therapeutic exercise include one iliotibial band perform exercises in proper form without pain [11,33]. Other outcome measures include strength testing the gluteus

Figure 14. Resisted staggered squat is an intermediate exercise to facilitate gluteal muscles and an alternative functional Figure 16. Posterior lunge slide is a more vigorous leg exercise stance. for functional hip control. 560 Baker et al ILIOTIBIAL BAND SYNDROME

modifications: (1) flat terrains, (2) controlled mileage (ie, 1/2 mile for 2 weeks), (3) easy pedalling at 80 revolutions per minute, and (4) pain free.The investigators also modified the bicycles based on misalignments identified during the evaluation of bicycle fit, for example, adjusting cleat or pedal positions to reflect the cyclist’s normal off-bicycle alignment and lowering the seat to achieve 30°-32° of knee flexion at the bottom center of the pedaling stroke. Floating pedal systems were selected when fixed pedals did not allow for correction of anatomic variants, and 2-mm spacers were used to correct a short leg.

CONCLUSION Several intrinsic and extrinsic contributing factors for ITBS have been described. Reduced hip muscle performance and Figure 17. Single-leg dead lift is a more vigorous single-leg abnormal hip and knee mechanics during functional tasks exercise to emphasize gluteus maximus, gluteus medius, and may be primary contributors to ITBS. Addressing these un- hip control. derlying factors is critical to the efficient management of patients with this condition. Although controversy exists medius and gluteus maximus with a normal result [36,38]. regarding the mechanism of ITBS, controlling inflammation The flexibility of the iliotibial band and rectus femoris can be and symptoms during early phases and progressive strength- assessed with a modified Thomas test as previously described ening in later phases is recommended. ITBS remains a com- [43,44]. The Ober test can be used to assess hip adduction mon and challenging dysfunction in many athletes; but, range of motion as previously described [42]. Our recom- through early diagnosis and proper biomechanical move- mendation on flexibility testing and return to sports is pain- ment analysis, appropriate interventions can be implemented free range of motion in hip adduction. There should be a to decrease pain and to improve function. negative Noble compression test, with the absence of tenderness at the lateral epicondyle of the femur at 30° knee REFERENCES flexion [9]. Runners and cyclists should train on level ground every 1. Ellis R, Hing W, Reid D. Iliotibial band friction syndrome—a systematic review. Man Ther 2007;12:200-208. other day [33,60]. The distance and frequency of training 2. Farrell KC, Reisinger KD, Tillman MD. Force and repetition in cycling: should be increased incrementally and monitored for the possible implications for iliotibial band friction syndrome. Knee 2003; recurrence of symptoms. Cross training is not recommended 10:103-109. if the activities involve repeated knee flexion through the 3. Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oest- impingement zone, such as combining hill running, track reicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med 2000;10:169-175. running, swimming, and cycling [10,29]. Orthotic recom- 4. Holmes JC, Pruitt AL, Whalen NJ. Iliotibial band syndrome in cyclists. mendations are worth considering in a runner if the patient Am J Sports Med 1993;21:419-424. has excessive calcaneal eversion and tibial internal rotation 5. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, during functional tasks and increased leg length greater than Zumbo BD. A retrospective case-control analysis of 2002 running 0.5 cm [5,26]. injuries. Br J Sports Med 2002;36:95-101. 6. Renne JW. The iliotibial band friction syndrome. J Bone Joint Surg Am The cyclist is advised to check bicycle fit for factors related 1975;57:1110-1111. to the 30° impingement zone and the toe-in position [2]. 7. Kirk KL, Kuklo T, Klemme W. Iliotibial band friction syndrome. Wanich et al [60] recommended lowering the seat beyond Orthopedics 2000;23:1209-1214. the typical height to decrease knee extension and related 8. Orava S. Iliotibial tract friction syndrome in athletes—an uncommon iliotibial band stress, and more upright handlebars and a exertion syndrome on the lateral side of the knee. Br J Sports Med 1978;12:69-73. forward seat to reduce passive stretch to the gluteus maximus 9. Noble C. Iliotibial band friction syndrome in runners. Am J Sports Med and iliotibial band. The investigators also recommended 1980;8:232-234. addressing cleat position and use of orthotics, such as 10. Orchard JW, Fricker PA, Abud AT, Mason BR. Biomechanics of iliotibial band wedges, to control excessive tibial internal rotation and foot friction syndrome in runners. Am J Sports Med 1996;24:375-379. hyperpronation. Flexibility was emphasized for the gluteus 11. Adams WB. Treatment options in overuse injuries of the knee: patellofemoral syndrome, iliotibial band syndrome, and degenerative menis- maximus and iliotibial band and, more generally for the cal tears. Curr Sports Med Rep 2004;3:256-260. hamstrings and gastroc-soleus muscles. Holmes et al [4] 12. Hamill J, Miller R, Noehren B, Davis I. A prospective study of iliotibial band treated 61 cyclists with ITBS by using the following training strain in runners. Clin Biomech (Bristol, Avon) 2008;23:1018-1025. PM&R Vol. 3, Iss. 6, 2011 561

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