IT BAND SYNDROME
Robert H. Sheinberg, DPM
The term iliotibial band friction syndrome (ITBFS), or IT band
syndrome, refers to a syndrome of knee pain on the outside edge
related to irritation and inflammation of the part of the iliotibial
band at, or just below, the point at which it crosses the outside
edge of the knee.
It is a well-recognized cause of knee pain in runners so it is
commonly called "runner's knee", although the condition
is not unique to runners. It can also be seen in cyclists, weight
lifters, skiers and soccer players.
The iliotibial band itself is a thickened strip of connective tissue
that connects at the front bone of the pelvis and extends across
the knee to the shin bone. Two muscles, one located in the buttocks
and one close to the hip on the outside of the thigh, attach to
the iliotibial band. Due to the course of the IT band, it is an
important stabilizer of the hip and knee as both of these joints
flex (bend) and extend (straighten) while running. During weight
bearing activities, compression and friction forces increase where
the IT band rubs against the knee area and pain occurs. Also during
weight bearing, there is a contraction of the surrounding muscles,
which tightens the knee joint. This leads to more friction over
the outside edge of the knee where the iliotibial band crosses it
and pain is increased.
The average jogger makes 3,000 foot strikes per mile. That is 60,000
foot impacts for every twenty miles. Each leg impact must bear the
entire body weight by itself-because in running you only have one
foot on the ground at a time. (In walking, 30 percent of the time,
both feet are on the ground). The force of landing is about three
times your weight. that means that if you weigh 150 pounds, the
force when you land is around 450 pounds Shoe mileage should also
be considered. After 500 miles most shoes retain less than 60% of
their initial shock absorption capacity
If you have a minor abnormality in your foot or leg anatomy the
force of the foot strike is passed to the knee area. Common causes
include genu varum (bow-legged) cavus feet (high arches), footwear
excessively worn on the outside heel, leg length discrepancies,
cleat position and seat height for cyclists, and runners with severe
overpronation (flattening of the feet). Also, running on crowned
or cambered (angled) running surfaces (most roads drop off toward
the side) will put abnormal stress and strain on the area, as well
as running hills or stairs.
Although cycling is considered to be less abusive to weight
bearing
joints, there is potential for overuse problems from repetition.
In cycling, with each pedaling stroke, the ITB is pulled in front
of the knee on the down stroke and in back of the knee on the upstroke.
Knee flexion and extension occur approximately 4800 times an hour
(at an average cadence of 80 pedal revolutions per minute), so the
ITB is especially susceptible to repetitive irritation.
Active pronation with internal knee rotation increases tension
on the ITB. Cleat position should be corrected to reflect the cyclist's
anatomic alignment or can be externally rotated to reduce stretch
on the ITB. Seat position may be too high or too forward and should
be adjusted to 30 to 35 degrees of knee flexion at dead bottom of
the pedaling stroke. Excessive hill work and increased mileage can
also cause problems in the cyclist.
ITB friction syndrome usually starts with minor discomfort, and becomes progressively
worse. Sometimes it begins after a single run. Quite often
a patient will feel so good with a small run and they continue for
a few more miles, thus bringing on the problem. The pain is located
almost always on the outer aspect of the knee.
The degree of discomfort runs from a dull aching sensation to a
sharp stabbing pain. The pain is not localized. Most sufferers of
ITB friction syndrome cannot put their finger on one particular tender spot. They
will usually use the flat of their hand to describe the location
of the pain.
In establishing an appropriate treatment program, the grade of severity
of the present inflammation must first be determined. With the inflammation
properly assessed and the diagnosis taken into consideration, the
athlete may be placed into one of the three phases of ITB care.
The first phase of care is the Immediate Phase. This is
the phase in which pain and inflammation are to be controlled and
any poor training habits, structural abnormalities (cavus feet,
bow-legged), or functional abnormalities (pronated foot, tight musculature)
are identified and corrected. Achievement of these goals requires
a reduction of activity and the appropriate administration of anti-inflammatory
measures. Such appropriate treatments may include: oral anti-inflammatory
medications, ice, heat, ultrasound, and/or electrical stimulation.
It must also be noted that stretching exercises are also used here
to combat any excessive ITB tightness.
Phase two, or the Short Term Phase, becomes a consideration
if painful symptoms do not resolve within approximately 10 days
of the documented onset. Previous treatment should be continued
at this point with the possible addition of steroid injections (given
in 2-week intervals) and further restriction of activity may be
a necessity.
If loss of musculoskeletal and/or aerobic conditioning becomes
a concern during this phase of rehabilitation, he/she may participate
in other activities so long as the activity remains pain-free.
The third, and optimistically final, stage of the treatment is
known as the Long Term Phase, begins only after pain and
inflammation are resolved and typically in close association with
the athlete's return to sport. During this stage, it is of utmost
importance to prevent any reoccurrence of the resolved symptoms.
A gradual return to play with extensive structurally specific stretching
exercises both before and after workout is essential to ensure rehabilitation
success.
If training errors have not been corrected or inflammation significantly
reduced, return to activity will not be satisfactory.
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