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
Bananas Or Barbells

Bananas or Barbells – How to prevent Cramps during Running?

Bananas or Barbells - What works for preventing Cramps during Running?

Introduction:

Exercise Associated Muscle Cramps (EAMC) is one of the most common conditions that require medical attention during or immediately after sports events. EAMC is particularly common in endurance events such as marathons and the etiology is poorly understood. Studies have reported an EAMC prevalence of 18% during a road marathon and 41% during a 56-km ultramarathon. It’s a key reason why inexperienced runners fail to finish their marathon.

 

Presentation and Proposed Aetiology

EAMC have a typical clinical presentation resulting from intense and prolonged physical exercise, and they usually occur in muscles subjected to high contractile demand during exercise exertion. The first and most popular hypothesis about the etiology of EAMC was the dehydration and electrolyte depletion theory, in fact, most runners still believe that sodium intake during endurance exercise prevents the occurrence of muscle cramps. It’s based on the traditional view of exercise-associated muscle cramps, which attributes them to dehydration and the loss of electrolytes like sodium and potassium (which bananas contain in abundance) from prolonged sweating. A survey of 344 endurance athletes found that 75% believe that taking extra sodium can help to prevent muscle cramps (McCubbin et al, 2019).

 

So, Is it True that Muscle Cramps are due to electrolyte imbalance?

A recent study by Martinez-Navarro et al (2020) compared dehydration variables, serum electrolytes, and muscle damage serum markers between runners who suffered EAMC and runners who did not suffer EAMC in a road marathon.

98 marathoners took part in the study. Before and after the race, blood and urine samples were collected and body mass was measured. In the study, 88 runners finished the marathon, and 20 of them developed EAMC (24%) during or immediately after the race. Body mass change, post-race urine specific gravity, and serum sodium and potassium concentrations were not different between crampers and non-crampers.

Conversely, runners who suffered EAMC exhibited significantly greater post-race creatine kinase and lactate dehydrogenase (LDH). The difference in the percentage of runners who included strength conditioning in their race training approached statistical significance.

muscle cramping in the marathon

Therefore, runners who suffered EAMC did not exhibit a greater degree of dehydration and electrolyte depletion after the marathon but displayed significantly higher concentrations of muscle damage biomarkers. Further, 48 % of the non-crampers reported regular lower limb resistance training compared with 25 percent of the crampers.

 

Key Take-away from this Study

Contrary to popular belief, runners who suffer EAMC do not exhibit a greater degree of dehydration and electrolyte depletion after endurance events like a marathon but display significantly higher concentrations of muscle damage biomarkers. It seems that cramps occur in muscles that are fatigued to the point of damage and it might be a protective strategy by the body to prevent further muscle damage. Further, regular lower limb strength training might be protective in reducing the incidence of EAMC.

So, rather than eating a lot of bananas before an event, regular strength training might be a better strategy in reducing the incidence of cramps in long-distance runners.

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:

McCubbin AJ, Cox GR, Costa RJ. Sodium intake beliefs, information sources, and intended practices of endurance athletes before and during exercise. International journal of sport nutrition and exercise metabolism. 2019 Jul 1;29(4):371-81.

Martínez-Navarro I, Montoya-Vieco A, Collado-Boira E, Hernando B, Panizo N, Hernando C. Muscle cramping in the marathon: dehydration and electrolyte depletion vs. muscle damage.

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