Tendinopathy and Iliotibial Band Syndrome: Understanding Pathology Informs Treatment

Craig R. Denegar, Ph.D., P.T., A.T.,C. Professor and Associate Department Head Director, Doctor of Physical Therapy Program Department of Kinesiology University of Connecticut [email protected] Invitation

Address the contemporary use of one or more therapeutic modalities

EATA 2010 2 Premise

At the foundation of therapeutic interventions for musculoskeletal conditions lies a diagnosis (medical, functional)

EATA 2010 3 Purpose

Consider therapeutic interventions from a perspective of new understandings of two relatively common musculoskeletal conditions Highlight the links between diagnosis from a tissue and biomechanical perspective and treatment recommendations

EATA 2010 4 Tendinopathy

Tendinosis or Tendinitis Implication of “itis” Implications of labeling in treatment

EATA 2010 5 What it is: A closer look at a degenerative process

Ultrasonography Fiber disorganization Hypoechoic islands Increased fluid volume Increased diameter Neovascularization

EATA 2010 6 Transverse View 5 cm prox insertion

EATA 2010 7 Ultrasound: Achilles Rupture

EATA 2010 8 Neovascularization

From: Hoksrud A. et al. Ultrasound-guided sclerosis of neovessels in painful chronic patellar tendinopathy: a randomized controlled trial. Am J Sports Med. 2006; 34:1738-46. EATA 2010 9 Collagen Organization: H&E

EATA 2010 10 Signs and Symptoms

Pain

Why is tendinopathy painful?

Stiffness

What does loss of stiffness imply?

EATA 2010 11 Neovascularization

Not always present

Resolution has been associated with symptom relief

May be present in asymptomatic individuals

EATA 2010 12 What it is not: highlights of the literature

“There is some scientific support in the literature for the diagnosis of tenosynovitis and tendinosis as a pathologic entity. Actual inflammation of tendon tissue consistent with tendonitis has not been seen clearly in patho- anatomic studies” Almekinders LC, Temple JD. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc 1999 31:352-3

EATA 2010 13 What it is not: bottom line

Tendinopathy is not an inflammatory condition based upon contemporary understanding of an acute inflammation > repair process.

PGEs elevated but not neutrophil, macrophage counts

EATA 2010 14 Treatments suggested for “itis”

Ultrasound & phoresis(how many have used US to treat a tendinopathy?) NSAIDs Friction massage LLLT Exercise Superficial heat and cold

EATA 2010 15 Ultrasound etc.

“Therapeutic ultrasonography, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit for tendinopathy.” Wilson JJ, Best TM Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician. 2005 Why would we treat a non-inflammatory condition with anti-inflammatory medication or suggest we promote resolution of an inflammatory condition with ultrasound, especially in light of the absence of evidence of efficacy?

EATA 2010 16 Friction massage

No benefit but limited to ECRB and ITB – further investigation needed

Brosseau L, Casimiro L, Milne S, Welch V, Shea B, Tugwell P, Wells GA. Deep transverse friction massage for treating tendinitis. Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD003528. DOI:10.1002/14651858.CD003528.

EATA 2010 17 NSAIDs

NSAIDs are recommended for short-term pain relief but have no effect on long- term outcomes.

Wilson JJ, Best TM Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician. 2005

EATA 2010 18 NSAIDs

“Overall, a short course of NSAIDs appears a reasonable option for the treatment of acute pain associated with tendon overuse, particularly about the shoulder. There is no clear evidence that NSAIDS are effective in the treatment of chronic tendinopathy in the long term.” Andres BM, Murrell GAC. Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon. Clin Orthop Relat Res. 2008 466: 1539–1554.

EATA 2010 19 LLLT

Mixed results Systematic reviews do not support use of LLLT for tendinopathy Results may be parameter specific See: Bjordal JM, et al. A systematic review with procedural assessments and meta- analysis of Low Level Laser Therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskelet Disord. 2008; 9: 75.

EATA 2010 20 LLLT

Bottom line – we have much to learn regarding LLLT and the treatment of tendinopathy Additional data are needed before LLLT with specific treatment parameters (wavelength, dose etc.) can be recommended for general care

EATA 2010 21 Exercise

Limited levels of evidence exist to suggest that EE has a positive effect on clinical outcomes such as pain, function and patient satisfaction/return to work when compared to various control interventions such as concentric exercise (CE), stretching, splinting, frictions and ultrasound. Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise British Journal of Sports Medicine 2007;41:188-198

EATA 2010 22 Effective treatment ‐ exercise

Achilles and patella Evidence of response to progressive eccentric loading

Less benefit with insertional Achilles pathology often including bursitis, Haglund’s deformity

EATA 2010 23 Effective treatment‐exercise

Evidence of benefit of closed chain incline squat in management of patella tendinopathy Posterior tibialis: preliminary evidence of benefit with brace (FAO)-> orthotic and eccentric loading

EATA 2010 24 A New Approach

Glyceryl Trinitrate Patches Evidence of effectiveness – new solution based on a new understanding of tendon pathology ? Paoloni et al. Topical Glyceryl Trinitrate Application in the Treatment of Chronic Supraspinatus Tendinopathy:A Randomized, Double-Blinded, Placebo-Controlled Clinical Trial . Am J Sports Med. 2005;33:806–813

EATA 2010 25 GTN

GTN reduced pain with activity at 12 & 24 wks, reduced night pain at 12 wks, reduced tenderness at 12 wks, decreased pain after the hop test at 24 wks, and increased ankle plantar flexor mean total work compared with the baseline 24 wks. 78% of GTN group were asymptomatic with activities of daily living at six months, compared with 49%) in placebo group. The mean effect size for all outcome measures was 0.14. Paoloni et al. Topical Glyceryl Trinitrate Treatment of Chronic Noninsertional Achilles Tendinopathy. JBJS (Am) 2004; 86:916-922

EATA 2010 26 GTN

Kane et al. Topical Glyceryl Trinitrate and Noninsertional Achilles Tendinopathy: A Clinical and Cellular Investigation. Am J Sports Med. 2008;36:1160-3. “This study has failed to support the clinical benefit of GTN patches previously described in the literature. In the available tissue samples, there did not appear to be any histological or immunohistochemical change in Achilles tendinopathy treated with GTN compared with those undergoing standard nonoperative therapy.”

EATA 2010 27 Concerns with “Recovery”

Resolution of symptoms does not imply structural repair Evidence of repair Decrease diameter Resolution of vascular in-growth Improved fiber organization and resolution of hypoechoic islands No treatment universally effective – fuller understanding of pathology needed to advance treatment EATA 2010 28 Current best practice? EdUReP+

Educate the patient Unload – active rest, brace as indicated Glyceryl Trinitrate Patch? Reload – eccentric training Prevent – training errors, too rapid of a return to sport

EATA 2010 29 A new tale: complaint of lateral knee pain

Active graduate student in good health

Pain on lateral aspect of right knee 10d

Insidious onset

Unable to run more than 1½ miles before onset of disabling pain

EATA 2010 30 Physical examination of right knee

Full motion No effusion No laxity Exquisitely tender over lateral femoral condyle

EATA 2010 31 Diagnosis?

If you hear hoof beats think of horses!!

EATA 2010 32 Nothing tricky

Athlete evaluated as experiencing Iliotibial Band Friction Syndrome

What is it?

How is the condition best treated?

EATA 2010 33 Iliotibial Band Friction Syndrome

EATA 2010 34 Varying opinions on the etiology of the injury

EATA 2010 35 Biomechanics

With knee extension, the ITB is anterior to the lateral femoral epicondyle With greater than 30 degrees of knee flexion, the ITB is posterior to the lateral femoral epicondyle http://emedicine.medscape.com/article/307850-overview

EATA 2010 36 From PT Corner

What is a possible cause of iliotibial band friction syndrome? Overuse may cause shortening of the ITB. The knee goes from flexion to extension and excessive pressure from the ITB causes friction over the lateral femoral epicondyle. This repeated motion produces inflammation of the underlying structures and causes pain. http://www.nismat.org/ptcor/itb_stretch/ EATA 2010 37 Iliotibial band syndrome

The continual rubbing of the band over the lateral femoral epicondyle, combined with the repeated flexion and extension of the knee during running may cause the area to become inflamed.

http://en.wikipedia.org/wiki/Iliotibial_band_syndrome

EATA 2010 38 Sports Injury Clinic

Runners Knee (Iliotibial band syndrome)

http://www.sportsinjuryclinic.net/cybertherapist/front /knee/irunnersknee.html syndrome)

EATA 2010 39 E‐medicine from Web MD

When the knee flexes, the ITB moves posteriorly along the lateral femoral epicondyle. Contact against the condyle is highest between 20° and 30° (average 21°), so when the band is excessively tight or stressed, the ITB rubs more vigorously. The space deep to the ITB is believed to have an adventitial bursal extension from the synovial capsule.

http://emedicine.medscape.com/article/1250716-overview

EATA 2010 40 Treatment??

Stretching

Ultrasound

Transverse friction

Etc.

EATA 2010 41 Second thoughts ?

Does the fascia become tight ?(or is there evidence that it can be substantially stretched?) The fascia is well anchored to the femur and does not rub on the femoral condyle!

EATA 2010 42 The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Fairclough et al, J Anat. 2006 Mar;208(3):309-16

EATA 2010 43 “the ITB is simply a thickened, lateral part of the fascia lata. It completely surrounds the thigh, is anchored to the femoral shaft by the lateral intermuscular septum and is continuous with the patellar retinacula”

EATA 2010 44 “Furthermore, we have shown that the ITB is firmly attached to the distal femur by strong, obliquely orientated, fibrous strands that can be regarded as tendon entheses. Thus, the ITB is unlikely to roll forwards and backwards during flexion and extension of the knee, but could move slightly in a medial–lateral direction.”

EATA 2010 45 “The impression of a rolling movement is likely to be an illusion created by a sequential shifting of tensile load within the ITB. Its fibres are tensioned in sequence from anterior to posterior as the knee flexes.”

EATA 2010 46 If the band does not roll across the lateral femoral condyle what would explain this commonly experienced and widely recognized problem?

EATA 2010 47 Is Iliotibial band syndrome really a friction syndrome? Fairclough et al J Sci Med Sport. 2007 Apr;10(2):74-6

EATA 2010 48 “Nevertheless, slight medial-lateral movement is possible and we propose that ITB syndrome is caused by increased compression of a highly vascularised and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle.”

*bursitis cannot be ruled out but …….

EATA 2010 49 MR findings in iliotibial band syndrome. Nishimura et al. Skeletal Radiol (1997) 26:533-537 “The MR finding suggested soft tissue inflammation and/or edema rather than focal fluid collection in a bursae”

EATA 2010 50 “Our view is that ITB syndrome is related to impaired function of the hip musculature and that its resolution can only be properly achieved when the biomechanics of hip muscle function are properly addressed.”

EATA 2010 51 Treatment

Iliotibial band friction syndrome – A systematic review. Ellis, Hing, Reid. Man Ther. 2007 Aug;12(3):200-8

EATA 2010 52 Reviewed 4 reports investigating NSAIDs, deep friction massage, phonophoresis vs immobilization, and corticosteroid injection

Outcome data confounded by other interventions (ice, stretching, rest)

EATA 2010 53 This review highlights both the paucity in quantity and quality of research regarding the conservative treatment of ITBFS. There seems limited evidence to suggest that the conservative treatments that have been studied offer any significant benefit in the management of ITBFS.

EATA 2010 54 Back to our patient

Very hypertonic over TFL Tender along course of palpatably tight ITB Palpation, long-sit suggestive of right anterior innominate rotation, T-L junction hypomobility Antecedents?

EATA 2010 55 Treatment

Mobilization of T-L jct, instruction in right knee to chest muscle energy and hip flexor muscle stretching 2-3 times each day. Initial treatment reduced TFL hypertonus and ITB tenderness Resume activity as tolerated

EATA 2010 56 Outcome

Able to resume running without limitation within 5 days

EATA 2010 57 Additional considerations

Runners – distance, surface, level of fitness, heel strike angle

Cyclists – saddle height, cleat peddle interface, distance

EATA 2010 58 Key points

Anatomical and MRI investigations suggest that pain over the lateral femoral condyle associated with ITB friction syndrome is not associated with friction but rather fat pad entrapment Tensioning of the ITB is due to proximal muscle / joint dysfunction Treatment should be directed at identifying and then treating the mechanical sources of ITB tensioning

EATA 2010 59 Bottom line

Understanding of the pathoetiology is essential to treatment decisions A multimodal approach (injection, manual therapy, therapeutic exercise) may yield optimal (early return to full sport participation) treatment results

EATA 2010 60 Future directions

Value of local interventions (corticosteroid injection, etc) warrants investigation in light of a revised view of the pain generator

EATA 2010 61 Questions and Discussion

EATA 2010 62 Thank you !!

EATA 2010