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Evidence Based Treatment for Iliotibial Band Friction Syndrome Review of Literature

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Evidence Based Treatment for Iliotibial Band Friction Syndrome Review of Literature December 2006 Keeping Bodies in Motion ® by Joshua Dubin, DC, CCSP, CSCS S PORTS T HERAPY Evidence Based Treatment for Iliotibial Band Friction Syndrome Review of Literature ABSTRACT: therapy, resulting in a more severe grade of injury. Pain Iliotibial band friction syndrome (ITBFS) is an may now be present with walking, exacerbated by walking inflammatory, non-traumatic, overuse injury of the knee up or down stairs, and a stiff-legged gait may be acquired affecting predominantly long-distance runners. A home to relieve symptoms.21 Based on clinical experience and as exercise program that includes a flexibility and strength a recreational runner, I have identified several reasons conditioning routine and modified training recommendations why most athletes are unwilling to temporarily discontinue can aid in the treatment and prevention of further injury. running: it is a time-efficient exercise; genuine friendships Most cases of ITBFS can be treated successfully with are formed in group training; no other cardiovascular conservative therapy. Recalcitrant cases of ITBFS may exercise can beat the “runner’s high”; and the fear of not require other interventions such as cortisone injections attaining his or her training goal. My experience and and/or surgery. research studies show conservative therapy to be extremely successful in the treatment of ITBFS.8,22 A proper treatment protocol should include the following: inflammation ILIOTIBIAL BAND FRICTION SYNDROME reduction, pain-free training modification, flexibility and Running has increased in popularity for cardiovascular endurance strength training of the muscles surrounding fitness and sport over the last decade.1,2,3,4 It has been estimated 5 the pelvis and thigh, and correction of faulty training that approximately 30 million Americans run for exercise. habits.1,2,7,8,9,10,11,12,13,23,24 However, it has also been projected that one-half to two-thirds The treating physician should have an understanding of of those runners may sustain a non-traumatic repetitive 5,6 the anatomy of the iliotibial tract, surrounding musculature strain injury at least once. Iliotibial band friction syndrome of the outer thigh and pelvis, the extrinsic and intrinsic (ITBFS) is an inflammatory, repetitive strain injury to the 1,7,8,9,10 risk factors that predispose long distance runners to knee that is particularly common in long distance runners. ITBFS, and the biomechanics of the ankle, tibia and knee ITBFS may be caused by a multitude of factors including during the stance phase of gait. training errors, worn out running shoes, and/or lower leg misalignments.1,4,11,12,13,14,15,16 The main symptom of ITBFS is a sharp pain on the outer aspect of the knee that can ANATOMY OF THE ILIOTIBIAL TRACT radiate into the outer thigh or calf.17,18,19 Knee pain usually Fascia is a sheath-like tissue that surrounds muscles occurs at a particular distance of each training run, probably and muscle groups. The fascia lata surrounds the hip and due to muscle fatigue,1,12 and is more pronounced shortly thigh. The iliotibial tract (ITT) is a lateral thickening of after the foot contacts the ground surface.20 Attempting to the fascia lata, originating from the iliac crest of the run throughout the pain will intensify the symptoms, pelvis. The ITT continues down the outer third of the eventually causing the athlete to shorten his stride or thigh, at the femur bone, passing over a protuberance walk. The frustrated athlete, who may be training for a called the greater trochanter. At the level of the greater race, will not be able to progress his mileage appropriately. trochanter, fibers from the gluteus maximus (GM) and However, the despondent runner may be unreceptive to Tensor fascia lata (TFL) musculature merge with the ITT advice to temporarily discontinue running and initiate posteriorly and anteriorly, respectively. Located between the ITT and greater trochanter is a bursa, a fluid filled sac initial contact and Fig. 3 Supination (Right Foot) that functions to decrease friction between two adjacent in preparation for structures. The ITT attaches superficially to the fascia of toe-off. Supination the vastus lateralis musculature, and through passage of consists of calcaneal the intermuscular septum to the linea aspera, a linear inversion (the heel Plantar ridge on the posterolateral aspect of the femur. As the ITT is turned inwards), Flexion approaches the knee joint, it passes over a protuberance plantar flexion (the on the outer aspect of the femur, the lateral femoral epicondyle toes approach the (LFE). A thin layer of fatty tissue is located between the ground surface) and Inversion ITT and LFE. As the ITT approaches the knee joint it splits adduction of the into two structures, the iliopatellar band and a distal forefoot (the toes Adduction extension of the ITT. The distal extension of the ITT crosses point toward the the knee joint and attaches to Gerdy’s tubercle, a bump midline) (Figure 3). Fig. 4 Pronation located on the proximal outer aspect of the tibia. The Ankle pronation (Right Foot) iliopatellar band migrates medially to join with the lateral occurs throughout retinaculum, a sheath-like tissue that attaches to the outer loading response 16,19,20,25,26,27,28,29,30,31 Ground aspect of the patella (Figure 1). The distal and into early mid Reactive extension of the ITT provides lateral stabilization to the stance, transforming Dorsiflexion knee joint through the foot and ankle Fig. 1 Anatomy of the Lateral Thigh its attachment to into a supple mobile the distal femur and adaptor that is Abduction the proximal tibia; efficient in absorbing Gluteus Maximus the iliopatellar ground reactive Tensor branch of the ITT forces. Ankle prona- Fascia Lata aids in decelerating tion consists of Eversion medial glide of eversion of the the patella and leg calcaneus (the heel flexion.32 turns outward), ground reactive dorsiflexion (the tibia moves Iliotibial Tract To properly forward over the foot) and abduction of the forefoot (the diagnose, treat, and toes and forefoot turn away from the midline) (Figure 4).2,35 Vastus Lateralis prevent ITBFS, a During initial physician should Fig. 5 Iliotibial Tract is located anterior contact the knee is Biceps to the Lateral Femoral Epicondyle with Femoris understand the knee extension. flexed approximately biomechanics of the 21 degrees,36 the ITT ankle, tibia, and should be located ante- Iliopatellar knee joint that this rior to the LFE, and the Iliotibial Band area undergoes Tract ankle is supinated during a typical (Figure 5). Throughout running gait, and loading response and how these move- early midstance, the ments dynamically ankle pronates, the tibia affect the ITT. Lateral internally rotates, the Femoral Patella Epicondyle knee joint flexes beyond LOWER LEG BIOMECHANICS WITH RUNNING 30 degrees, and the ITT Gait can be separated into two phases: the stance and translates posterior to the swing phases. This discussion will focus on the stance LFE (Figure 6). From phase, as it directly relates to ITBFS. During the stance early midstance and phase, the foot contacts and adapts to the ground surface; continuing into terminal during the swing phase, the leg accelerates forward and stance the ankle re- prepares for ground contact. The stance phase consists of supinates, the tibia externally rotates and initial contact, loading response, mid-stance, and terminal Fig. 6 Iliotibial Tract translates posterior 33 33 the knee re-extends. stance(Figure 2). The ankle joint, tibia, and knee joint to the Lateral Femoral Epicondyle with move in synchronicity during the individual stance phases, knee flexion. It has been proposed changing the lower extremity into a rigid lever for initial that ITBFS is secondary ground contact and toe-off, or a mobile shock absorber to repetitive knee from loading response and into early mid stance.34 movement through an Two tri-planar movements are particular to the ankle Iliotibial impingement zone of Tract 30 degrees of leg joint during the stance phase, supination and pronation. 9,10,17 The ankle assumes a supinated position for stability during flexion. This injury is Lateral most common in long Fig. 2 Femoral distance runners because Stance Epicondyle the activity involves Phases of Running repetitive leg flexion and Gait extension approximately 800 times per mile.37,38 The onset of pain asso- ciated with ITBFS will cause an athlete to Initial Loading Mid-stance Terminal Stance shorten his stride, Contact Response thereby limiting leg flexion and minimizing friction of the ITT over the gait,” raised ipsilateral hip, Fig. 8 inflamed fatty tissue and periosteal layer of the LFE. This and increased frontal plane Trendelenberg Gait altered gait will temporarily allow the athlete to continue adduction of the thigh and (raised hip on the running, but may exacerbate the condition. A study performed leg (Figure 8).1,42 This stance leg) on athletes who had acute or sub-acute clinical symptoms modified gait has been for ITBFS revealed MRI findings of fluid accumulation in shown to increase tension on the fatty tissue deep to the ITT.17,39,40 Secondary bursa or the ITT and is a risk factor thickening of the ITT may be more common in chronic for ITBFS.1,20 Pronounced stages of ITBFS.41 adduction of the stance leg Repetitive flexion and extension of the leg through the due to muscle fatigue leads 30 degree impingement zone may be one risk factor; however to increased tension on the the causes of ITBFS are multifaceted. Other risk factors ITT that may initiate or include training errors and structural misalignments. exacerbate symptoms related to ITBFS. TRAINING ERRORS AND RISK FACTORS FOR Excessive internal rota- tion of the tibia in the ITBFS transverse plane can also Training errors are contributory to most overuse running be caused by structural injuries.
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