ILIOTIBIAL BAND SYNDROME (ITB)

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ILIOTIBIAL BAND SYNDROME (ITB)
http//www.virtualphysicaltherapists.com/
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Iliotibial band (ITB) syndrome is one of the most
common overuse injuries in runners. It is also
seen in cycling and other activities that require
repetitive bending of the knee. Treatment must
focus on eliminating the causative factors.
Virtual Physical Therapy can help identify
biomechanical issues and educate you on how you
can get back to running pain-free!
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• ITB syndrome usually starts suddenly as
  discomfort or even burning on the outside of the
  knee. It can quickly turn into a sharp pain and
  quickly progress to a feeling of a vice around
  your knee that gets tighter and tighter until the
  pain stops you from moving. Initially, the
  symptoms are only brought on by aggressive
  activity such as running and cycling but as they
  progress, sitting with your knee flexed becomes
  unbearable, requiring straightening of the knee
  to release pressure.

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What Causes Iliotibial Band Syndrome? The number
one cause is too many miles! Minor issues with
running mechanics become exacerbated when
fatigued, and your muscles are weakened from
overtraining. Not allowing your body time to heal
leads to poor mechanics, tears in soft tissue,
damage. In the case of ITB syndrome it is due to
irritation and thickening of a fat pad over the
femoral epicondyle that the ITB repetitively
compresses. Banked surfaces (always running in
the same direction as road camber) and downhill
running (eccentric muscle control gives way
faster when fatigued) can cause increased stress
and compression of the ITB.
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Anatomy

• The ITB is a thick fibrous band extending from
  above your hip to below your lateral knee. The
  proximal portion begins as a sheath encasing the
  tensor fascia lata muscle. This sheath anchors
  the tensor fascia lata to the iliac crest and
  receives most of the superior gluteus maximus
  tendon. The dense ITB then extends all the way
  down the lateral leg and transitions to a
  ligamentous component, spanning from the lateral
  epicondyle of the femur (just above the outside
  knee) to five insertion points distally including
  the knee capsule and Gerdys tubercle just below
  the lateral knee.

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• Biomechanics
• The ITB acts as both a stabilizer for the hip and
  knee as well as elastic energy during walking and
  running. It is a distinctive tissue in that it
  has some properties of a tendon but most of a
  ligament. It is also unique because humans are
  the only mammal to have one. It is theorized that
  the ITB aids in our ability to stand on one leg
  and walk upright and is not needed in 4 legged
  mammals. We are not born with a distally
  inserting ITB, but rather developed as we learn
  to walk.
• The iliotibial band transmits the forces
  generated by the TFL and gluteus maximus muscles,
  including thigh abduction, flexion, extension,
  and external rotation. The deep fascial
  component, which runs almost the entire femur
  length, is most taut when the gluteus maximus and
  TFL contract. This tensile action significantly
  increases during single-leg stance and serves to
  counteract medial bowing of the femur.

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• The ITB is actually a ligament/tendon hybrid
  because it has a bone-to-bone connection as seen
  in ligaments and muscle-to-bone connections as
  found in tendons. The ITB is NOT anchored to a
  bone at a clear, specific spot like most tendons.
  Instead, it blends into five different areas
  distally including the knee capsule. Tendons are
  smaller, dense connective tissue at the end of
  the muscle. The ITB, on the other hand, connects
  the muscles by a very thin sheath and is massive
  compared to the muscles it connects.
• The gluteus muscle pulls on the ITB to increase
  its tension laterally, like drawing a bowstring.
  It is then tightly anchored along the entire
  length of the femur, especially above the knee.
  The ITB does not really move freely in relation
  to the femur. It is firmly attached. The only
  slight movement may be at the insertion at
  Gerdys tubercle, just below the lateral knee.

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• Cause of Pain
• Iliotibial band syndrome occurs secondary to
  repetitive compression. Faulty mechanics caused
  an increase in compression at the distal end of
  the ITB as the hip extends and the knee flexes.
  The bony prominence of the lateral epicondyle has
  a protective synovial tissue or fat pad. This
  synovial tissue can become irritated, thickened,
  and even calloused. Once calloused, it can be
  felt like rubbing over a rubber band.

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• For many years it was believed that the pain was
  due to friction of the ITB over the lateral
  femoral epicondyle. The ITB is tethered to the
  distal femur, except for the upper portion of the
  lateral femoral condyle, preventing movement of
  the ITB across the lateral femoral condyle.
• Biomechanics that cause an increase in the
  compression of the ITB include genu varum (knees
  go inward), increased pronation, and hip
  weakness. These are in opposition to the role of
  the ITB, to pull on the femur laterally like a
  bowstring.
• The main problem and symptoms occur at 30 deg of
  knee flexion with the hip in slight extension
  this is when the ITB is mostly clamped down.

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• Misconceptions
• 1. The ITB is the painful structure. The painful
  tissue is underneath the ITB. It is synovium or
  tissue similar to a fat pad that is a lateral
  extension of the knee capsule. Repetitive stress
  causes it to become callused, and it gets
  pinched. Occasionally there can also be
  calcified loose bodies if the stress on this
  synovial tissue continues.
• 2. The ITB needs to be stretched using a foam
  roller or specific stretching. The ITB is mostly
  a ligament in structure. The role of a ligament
  is to maintain a taunt attachment to bone. You do
  not want loose ligaments as this leads to
  instability. The ITB is also a vast thick
  structure similar to a thick leather belt. You
  can pull on it all you want, and it still will
  not stretch. Foam rolling adds more compression
  to a tissue that has been already irritated by
  compression.

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• 3. Corticosteroid injections causes local cell
  death and tendon atrophy! Steroids have an
  important place in medicine but must be used with
  caution. Inflammation is part of the bodys
  natural healing process, and when it is
  terminated, it disrupts healing and can lead to
  tendon damage. The main treatment focus should be
  addressing the actual cause of ITB syndrome or
  repetitive stress/compression causing the tissue
  to become calloused.

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• Running
• Humans are built for running, and we may even be
  one of the best species for long-distance. Every
  year in Wales, there is an endurance race of
  humans against horses, and believe it or not,
  humans won twice because of hot conditions. If we
  are built for running, then why do we get so many
  injuries? Its because of poor mechanics and our
  training.

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• Running
• Humans are built for running, and we may even be
  one of the best species for long-distance. Every
  year in Wales, there is an endurance race of
  humans against horses, and believe it or not,
  humans won twice because of hot conditions. If we
  are built for running, then why do we get so many
  injuries? Its because of poor mechanics and our
  training.

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• Mechanism of Injury
• The ITB is most taunt when the hip is extended
  and the knee is flexed to 30 degrees. The hip
  goes into extension during the swing phase of
  running when the knee bends. Severe symptoms
  almost completely abolish as soon as the
  individual stops walking because the hip does not
  extend in walking. The faulty mechanics found in
  those that suffer from ITB on the painful side
  include
• 1. Hip drops down and in (adducts)
• 2. Ankle bone drops down and in (pronation)
  during heel strike
• 3. Heel is inward during the swing phase.

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• The faulty mechanics are exacerbated with fatigue
  as the muscles tire leading to weakness in hip
  abduction weakness causing the hip to drop inward
  and tibialis anterior fatigue causing pronation
  of the foot. Road cadence constantly running on
  one side of the road places uneven stress on the
  leg, and poor footwear can cause increased
  pronation.

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• Physical Evaluation
• 1. A good clinician will first RULE OUT the
  lumbar spine. There is a high incidence of
  isolated extremity symptoms originating from the
  spine. Therefore the spine must always be
  screened. This is easily done by moving the spine
  to see if it has any effect on the symptoms of
  complaint along the outer knee.
• 2. Observation Screen for alignment and any
  abnormalities
• 3. Palpation Assess for any tenderness and
  palpable bursa along the lateral femoral
  eopicondyle.
• 4. Test for ITB Syndrome Have the individual
  repetitively flex and extend the knee with hip in
  extension. A positive test is the reproduction of
  lateral knee pain.
• 5. Muscle strength (hip abduction, external
  rotation, quad, foot)
• 6. Flexibility quad, hamstring, calf, and soleus
• 7. Gait/running assessment

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• Rehabilitation
• Active REST
• An initial rest from running in favor of another
  aerobic activity cycling, swimming, etc. so
  activity can continue while eliminating
  compression over the lateral epicondyle.
  Gradually return to running (initially avoid
  downhill) 3 days to 6 weeks depending on the
  individuals symptoms. Average avoidance of
  running 1 week. (2-6 months until recovery is
  complete)
• Address limitations
• Full quad, hamstring, and calf flexibility
• Improve hip, knee, and foot strength

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• Address running mechanics
• Land with ankle bone high
• Swing phase with heel out
• Return to running
• Faster, shorter runs initially (Slow running
  causes increased pressure on ITB. Sprinting
  reduces compression.)
• Adjust running style shorter stride and lower
  (initially)
• Avoid downhill
• Gradually increase millage

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• Prevention
• Learn proper running mechanics (GOATA). Schedule
  an assessment with one of our GOATA specialists.
• Training!!!! Gradual increase in millage
• Maintain adequate strength and flexibility
• Avoid always running on one side of the road if
  there is camber

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Virtual physical therapists

• info.virtualphysicaltherapists_at_gmail.com

• http//www.virtualphysicaltherapists.com/