ITBS - Facts Or F(r)iction?

ITB Syndrome – Facts or F(r)iction?

ITB Syndrome/Runner’s Knee – Facts Or F(r)iction

Is ITB syndrome also called runner’s knee really caused by friction and caused by a tight ITB?
Should we stretch and foam roll or is it all about glute training?
We will answer these and more common questions in this myth-busting blog post!

First of all, we would like to thank Lizzie Marlow who gave a fantastic speech at our 1st Physiotutors conference about ITB syndrome. This post is basically Lizzie’s talk in a nutshell with a few inputs from us here and there. So let’s look at myth number 1:

1) ITB syndrome is the only source of lateral knee pain.

First of all ITB syndrome is certainly the most prevalent cause of lateral knee pain with a reported incidence as high as 12% of all running-related overuse injuries. There are surely other sources that can cause pain at the lateral knee. Typical signs & symptoms for ITB syndrome are worse pain when running downhill or on narrow trails and a spike in training volume history. If the patient reports pain posterolaterally, you will have to take distal femoral biceps tendinopathy into account. In contrast to ITB syndrome, biceps tendinopathy worsens when running uphill, is worse with higher speeds, but gets better when warmed up.

Furthermore, you have to consider patellofemoral pain which is very common in runners. PFPS is usually worse with loaded flexion, walking stairs, or after prolonged sitting – also called the Cinema sign. At last, lateral meniscus pathology or early osteoarthritis might be a cause of pain in runners regularly running on hard surfaces, who report pain on deep squatting or twisting the knee. This more prevalent in patients above the age of 40. Even some morning stiffness might be present in this group.
To conclude: ITB syndrome is not the only cause of lateral knee pain.

 

Cadaveric speciment of the

Godin et al. (2017) - Figure 1. Cadaveric specimen demonstrating the fiber orientation
of the proximal and distal iliotibial band fibers (Kaplan
fibers) in a right knee. FCL, fibular collateral ligament; ITB,
iliotibial band; PLT, popliteus tendon.

2) ITB syndrome is caused by friction & Rubbing over the bursa at the lateral epicondyle of the femur.

Originally, the idea behind ITB syndrome was that the ITB flicks over the lateral epicondyle of the femur. This would occur at around 30 degrees of flexion when the ITB changes its force direction from an extension force at the knee to a flexion force or vice versa. However, Fairclough and colleagues (2006) showed that there is actually no native bursa under the Iliotibial band. On top of that, the same authors (2007) showed that the Iliotibial band is anchored to the distal femur by fibrous strands making friction at the knee impossible. The sensation of “flicking” that runners report is rather an illusion of movement that is created by changing tension in the ITB’s anterior and posterior fibers during knee flexion. But what is ITBS then? The author's reason that the band moves medially during knee flexion as a consequence of tibial internal rotation which compresses the fat pad under the ITB against the epicondyle. With extension, the ITB moves laterally again. Excessive compression of the fat pat may trigger an inflammatory response which could be the nociceptive generator in ITBS.

 

 

3) ITB syndrome caused by a tight ITB

First of all: How do we know if the ITB is tight? We’ve mentioned this earlier on our channel, but a study by Willett et al. (2016) have shown that Ober’s test is not a valid test for ITB shortening.

Instead, it rather measures a shortening of the hip capsule. The only thing we have to “diagnose” ITB syndrome is provocation tests like the Renne’s and Nobel Compression test that you can watch below:

 

4) Stretching and foam rolling are effective treatments for ITB syndrome

A study by Seeber et al. (2020) has looked at the stiffness of the ITB band. They concluded that the ITB can withstand substantial forces and is basically inextensible. Moreover, they found that it actually ruptures at around 80 kilograms of tension. For this reason, the authors concluded that clinical stretching will probably not lead to prolonged elongation of the band.

At the same time, the ITB gets foam-rolled a lot in physio practices and gyms all over the world. However, the expectation that foam rolling will break down adhesions or lengthen the ITB band is unrealistic. Just looking at it from a biomechanical standpoint, a compression without stretch cannot lead to an elongation. What may be possible is to stretch the muscles that attach to the ITB, but then again we have discussed the limitations of stretching on muscle elongation in another video. What stretching probably achieves is an increased pain-tolerance to stretch in short term. What a study by Wilhelm et al. (2017) found is that the tensor fascia latae muscle is actually capable of elongation in response to a clinical stretch in contrast to the ITB, but they are calling for future research to see if there is actually permanent elongation. Our prediction is: they’re probably not going to find any permanent lengthening. We would be very surprised if this is different in the TFL compared to other muscles.

Seeber et al. (2020): Individual specimens' values for load and absolute deformation.

At last, if we assume that ITBS is caused by excessive compression rather than friction then all of these approaches would just lead to further irritation of the fat pat underneath the ITB. So those treatments probably make ITBS worse.

 

5) It’s all in the glutes

So how do we treat ITBS then? The general recommendation is to strengthen the glutes in order to reduce hip adduction and thus reduce the stress on the ITB.
This very much depends on the patient: While there are patients with an increased valgus that might surely benefit from hip strengthening, the second group displaying ITBS are commonly men with knee varus.

In this group, hip training might not be as effective as in group 1. On top of that, a study by Willy et al. (2012) has shown that glute training does not change biomechanics.

For runners, it eventually boils down to a mix of addressing running biomechanics, addressing training errors, and neuromuscular deficits.

To learn more about the management of runners with injuries, including initial rehab, load management, strength training, and running re-training, check our comprehensive online Running Rehab Course with access to all information related to the rehab of running injuries.

Thanks a lot for reading! 

Cheers,

Kai

 

References:

Godin JA, Chahla J, Moatshe G, Kruckeberg BM, Muckenhirn KJ, Vap AR, Geeslin AG, LaPrade RF. A comprehensive reanalysis of the distal iliotibial band: quantitative anatomy, radiographic markers, and biomechanical properties. The American journal of sports medicine. 2017 Sep;45(11):2595-603.

Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of anatomy. 2006 Mar;208(3):309-16.

Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M. Is iliotibial band syndrome really a friction syndrome?. Journal of Science and Medicine in Sport. 2007 Apr 1;10(2):74-6.

Seeber GH, Wilhelm MP, Sizer Jr PS, Guthikonda A, Matthijs A, Matthijs OC, Lazovic D, Brismée JM, Gilbert KK. THE TENSILE BEHAVIORS OF THE ILIOTIBIAL BAND–A CADAVERIC INVESTIGATION. International journal of sports physical therapy. 2020 May;15(3):451.

Wilhelm M, Matthijs O, Browne K, Seeber G, Matthijs A, Sizer PS, Brismée JM, James CR, Gilbert KK. Deformation response of the iliotibial band-tensor fascia lata complex to clinical-grade longitudinal tension loading in-vitro. International journal of sports physical therapy. 2017 Feb;12(1):16.

Willett GM, Keim SA, Shostrom VK, Lomneth CS. An anatomic investigation of the Ober test. The American journal of sports medicine. 2016 Mar;44(3):696-701.

Willy RW, Davis IS. The effect of a hip-strengthening program on mechanics during running and during a single-leg squat. Journal of orthopaedic & sports physical therapy. 2011 Sep;41(9):625-32.

ATTENTION THERAPISTS WHO FIND DIFFERENTIAL DIAGNOSIS WITH BUTTOCK PAIN IN RUNNERS DIFFICULT

Level Up your Differential Diagnosis in Running Related Hip Pain - For FREE!

Don't run the risk of missing out on potential red flags or ending up treating runners based on a wrong diagnosis! This webinar will prevent you to commit the same mistakes many therapists fall victim to!

Hip Pain in Runners
Don’t miss Femoral Stress Fractures in the Female Runner!

Don’t miss Femoral Stress Fractures in the Female Runner!

Don’t miss Femoral Stress Fractures in The Female Runner!

Case Study:

A 28-year-old woman presents to the physiotherapy clinic with a 3-week history of left groin and anterior thigh pain that has progressively worsened while training for her first half-marathon. She has reduced her training schedule to two sessions a week due to her pain and is currently unable to run beyond 15 minutes.


What is the ONE condition that you don’t want to miss in this runner?

A stress fracture is caused by repeated sub-optimal loading on a bone over time as opposed to a single severe impact. Stress fractures in the hip and pelvis region (femoral neck, pubis, sacrum, and ischium) are more common in female runners and should not be missed, as a possible differential diagnosis of hip and groin pain. Femoral stress fractures account for around 11% of all stress fractures in the athletic population.

 

Risk Factors

There are multiple risk factors for the development of stress fractures within the athletic population. The key risk factors for stress fractures are highlighted below, as a checklist.

Stress Fracture Checklist

 

Clinical Presentation

In female runners, a history comprising of amenorrhea reduced calorie intake, and previous bone stress injuries should raise the suspicion of a stress fracture (Lodge et al. 2021).  Most runners usually present with vague symptoms about the hip and groin region.  Typically, the pain is diffuse around the groin, anterior hip and can radiate to the proximal thigh region. Tenderness is rarely elicited, even with severe stress fractures. The pain typically worsens with impact activities and worsens over time. In advanced cases, it may progress to night pain and even limping during walking (Petrin et al. 2016).

Femoral neck stress fractures are more concerning due to the risk of complete fracture, specifically for tension-type fractures on the superior neck. Compression fractures on the inferior neck are considered to be at much less risk of progression to complete fracture.

The risk of developing avascular necrosis following a displaced femoral neck fracture can be as high as 45% (Bachiller et al. 2002) and therefore, early recognition and management are crucial in the running population.

 

Physical Tests:

The single-leg hop test is sensitive for a stress fracture, although it should be used cautiously in runners with severe symptoms. Two useful tests which I use with runners in the clinic, with suspected femoral stress fractures are the fulcrum test and patellar percussion test, which are described below.

 

Fulcrum Test

Patella Percussion Test

 

Imaging:

A plain radiograph cannot reliably exclude a stress fracture. Also, plain radiograph often appears normal in the initial stages despite clinical signs and symptoms suggestive of a stress fracture (Groves et al. 2005).

MRI is the gold standard for confirmation of a stress fracture. The advantage of MRI is that it can detect ‘bone stress response’ often weeks, before visible changes are noted on radiographs (Pegrum et al. 2012), thereby enabling early intervention. Alternative imaging modalities for the diagnosis of stress fractures include bone scintigraphy.

 

Conclusion:

Female runners are at increased risk for stress fractures in and around the hip. Clinicians should have a high index of suspicion for stress fractures as the cause of hip and groin pain in the long-distance female runner. Insidious onset of a vague, poorly localized pain is particularly concerning.  A positive hop test combined with no specific tenderness raises particular concern for a stress fracture, which must be ruled out with imaging. Plain film X-rays are insufficient for early diagnosis and MRI imaging is recommended. Worsening hip pain in a runner and inability to bear weight should raise concern for serious hip pathology and prompt an urgent orthopedic referral.

 

Download our FREE FORM on Screening for Stress Fractures Checklist

by Clicking HERE!

 

This blog article is taken from our Running Rehab - From Pain to Performance Online Course. To learn more about the management of runners with injuries, including initial rehab, load management, strength training, and running re-training, check our comprehensive online Running Rehab Course with access to all information related to the rehab of running injuries.

Thanks a lot for reading! 

Cheers,

Benoy Mathew,

Lower Limb Specialist Physio

Creator (Running Rehab Course)

 

References:

Bachiller FG, Caballer AP, Portal LF. Avascular necrosis of the femoral head after femoral neck fracture. Clinical Orthopaedics and Related Research®. 2002 Jun 1;399:87-109.

Groves AM, Cheow HK, Balan KK, Housden BA, Bearcroft PW, Dixon AK. 16-Detector multislice CT in the detection of stress fractures: a comparison with skeletal scintigraphy. Clinical radiology. 2005 Oct 1;60(10):1100-5.

Lodge CJ, Sha S, Yousef AS, MacEachern C. Stress fractures in the young adult hip. Orthopaedics and Trauma. 2020 Apr 1;34(2):95-100.

Pegrum J, Crisp T, Padhiar N. Diagnosis and management of bone stress injuries of the lower limb in athletes. Bmj. 2012 Apr 24;344.

Petrin Z, Sinha A, Gupta S, Patel MK. Young man with sudden severe hip pain secondary to femoral neck stress fracture. Case Reports. 2016 Oct 26;2016:bcr2016216820.

ATTENTION THERAPISTS WHO FIND DIFFERENTIAL DIAGNOSIS WITH BUTTOCK PAIN IN RUNNERS DIFFICULT

Level Up your Differential Diagnosis in Running Related Hip Pain - For FREE!

Don't run the risk of missing out on potential red flags or ending up treating runners based on a wrong diagnosis! This webinar will prevent you to commit the same mistakes many therapists fall victim to!

Hip Pain in Runners
Why Runners Should Replace 'Lost Running Time' with other exercise

Why Injured Runners Should Replace ‘Lost Running Time’

Why Injured Runners Should Replace their ‘Lost Running Time’

Running-related injuries (RRIs) are frequent amongst the running population. The annual rate of running-related injuries ranges from 24 to 65%, with the most commonly injured joint being the knee (van Gent et al. 2007). Among runners training for a marathon, the injury rate has been reported as high as 90% (Franke et al. 2019).  The majority (around 80%) of running injuries are due to overuse with no clear traumatic event.

 

Physical Activity Behavior of Runners during Period of Injury

As many runners get injured, it is common that runners are unable to run during this period or while recovering from injury or during rehab.
So, do runners involve in other training methods like cycling or swimming to maintain their fitness, during this period? A recent study by Davis et al. (2020) has shown that it is not the case.

 

This study looked at 49 recreational runners and followed them for a year. All the runners were issued activity monitors to track their daily activity levels and they also completed a weekly survey about pain and training levels.  In this study, the definition of running injury was the inability to train for at least three sessions within a week.


Compared with uninjured weeks, runners engaged in few minutes of moderate to vigorous activity per day if they had an injury. Based on the results of this study, it seems that runners don’t replace lost running time with other exercises to maintain their fitness levels.

 

 

Key Take-away from this Study

As therapists, it is important that we are aware of the physical activity behavior of the injured runners, during the period that they are unable to run. It seems that runners are reluctant to engage in other forms of training when they are not running.

It is important that we encourage runners to maintain their cardiovascular fitness with plenty of low-impact ways to cross-train (e.g., Swimming, cycling, bodyweight routines) and keep them moving, instead of being sedentary. 

Being active comes with a lot of physical and mental benefits and can be beneficial to the injured runner when they are feeling down with the injury. A rest-only approach is not beneficial and regular involvement in cross-training will enable the runners to get back to pre-injury levels and an early return to running.

This blog article is taken from our Running Rehab - From Pain to Performance Online Course. To learn more about the management of runners with injuries, including initial rehab, load management, strength training, and running re-training, check our comprehensive online Running Rehab Course with access to all information related to the rehab of running injuries.

Thanks a lot for reading! 

Cheers,

Benoy Mathew,

Lower Limb Specialist Physio

Creator (Running Rehab Course)

 

References:

Van Gent RN, Siem D, van Middelkoop M, Van Os AG, Bierma-Zeinstra SM, Koes BW. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. British journal of sports medicine. 2007 Aug 1;41(8):469-80.

Franke TP, Backx FJ, Huisstede BM. Running themselves into the ground? Incidence, prevalence, and impact of injury and illness in runners preparing for a half or full marathon. journal of orthopaedic & sports physical therapy. 2019 Jul;49(7):518-28.

Davis JJ, Gruber AH. Injured Runners Do Not Replace Lost Running Time with Other Physical Activity. Medicine and science in sports and exercise. 2019 Dec 23.

ATTENTION THERAPISTS WHO FIND DIFFERENTIAL DIAGNOSIS WITH BUTTOCK PAIN IN RUNNERS DIFFICULT

Level Up your Differential Diagnosis in Running Related Hip Pain - For FREE!

Don't run the risk of missing out on potential red flags or ending up treating runners based on a wrong diagnosis! This webinar will prevent you to commit the same mistakes many therapists fall victim to!

Hip Pain in Runners