For those that remember, Laura experienced iliotibial band syndrome whilst we were running in New Zealand. I've also had this injury when hiking the Overland Track in Tasmania... from day 1 of 6. I've written a fairly comprehensive article about the injury. Where relevant I've included information about the meaning of words in Latin (look out for 'L.') as it helps with understanding the jargon. I've also added in my 2 cents about personal experience as an osteopath with the injury. Enjoy!
Anatomy of the ITB
The iliotibial tract or iliotibial band (ITB) is a sheath of fibrous connective tissue that runs longitudinally from the lateral (outer) pelvic/hip region, along the thigh to the lateral knee. It’s a very thick section of connective tissue measuring on average 1.95mm thick at the hip and 3.4mm at the knee (Goh et al., 2003). The thickness reflects the strength of the tissue; studies have shown that the ITB when dissected can withstand about 872 newtons of force which is about 89 kilograms (Seeber et al., 2020). This is figured out by stretching the tissue of cadavers.
Attachments of the ITB
There are a few structures that connect to and contribute to the function of the ITB. One is a band of connective tissue called fascia and the others are muscles.
Fascial attachment to the ITB: The fascia lata (L. band/swathe, broad). As the name explains, this is a broad band of fascia/connective tissue. It runs from the hip & pelvic bone region down the thigh, wrapping around and through muscles, attaching to bone. It forms three compartments in the thigh:
Lateral (L. side) intermuscular septum
Posterior (L. coming after) intermuscular septum
Medial (L. towards the middle) intermuscular septum
We're interested in the lateral intermuscular septum. It's located on the side of the thigh between the quadriceps muscle (vastus lateralis) & hamstring muscle (biceps femoris). The septum is a very strong band of fascia that adheres the ITB to the shaft of the femur (L. thigh bone). Often the ITB lacks pliability compared to other parts of the thigh. Personally I find that the intermuscular septum attachment prevents much movement/sliding from the ITB. It strongly adheres the ITB in place, and whilst this is what we need for normal movement, it likely places a lot of strain through the ITB. This is then potentially a big contributor to the cause of ITB syndrome.
Muscle attachments to the ITB:
1. Gluteus maximus. (L. rump, largest) The largest muscle in the body. It starts at the hip region and has most of its fibres attach to the ITB, a smaller number of fibres attach to the ischial tuberosity (the sit bone).
2. Tensor fascia latae (L. tenses, bandage, broad). Runs from the front of the hip bone (iliac crest) and attaches completely to the ITB. This is often a very tender area.
Attachment for the ITB at the knee
The ITB inserts to the outer aspect of the knee with various attachment points (forgive the jargon):
The lateral epicondyle of the femur
Gerdy’s tubercle (infracondylar tubercle of the tibia)
Longitudinal and transverse retinaculum of the patella (kneecap)
Head of fibula
Lateral intramuscular septum.
The most valuable clue from this is that ITB syndrome presents as pain around the outer knee, but due to how it has many locations in which it inserts, where the pain presents can be quite varied. Often sources will say that the pain is one particular spot of the knee but from our clinical experience, it can be at any of the above attachments.
Epidemiology of iliotibial band syndrome (who tends to get the injury)
According to research, the condition is more common in endurance athletes and is the most common lateral knee injury with an incidence rate of 1.6-15%. Furthermore, it accounts for 15% of all overuse injuries at the knee for cyclists.
We find that this condition arises in ages from teenagers to 60+ and of all levels of activity. This is due to the nature of the condition. As it’s a connective tissue injury, repetition plays a significant role and therefore athletes are more likely to be subject to the injury.
However, as a general rule of thumb, tissue that is unable to cope with the load placed on it is at risk of injury. So the condition is definitely not limited to athletes, and in the next section we’ll discuss the predisposing factors.
Pathomechanics of iliotibial band syndrome (movements, postures, etc that may cause the injury)
One proposed mechanism for the cause of ITB syndrome is that when the knee is bent and reaches the angle of 30 degrees, friction is believed to occur over structures at the outside of the knee (lateral femoral condyle). An alternate proposal is that rather than friction, compression occurs on the deeper tissue to the ITB, those being the lateral intermuscular septum.
Potential factors that can lead to or contribute to ITB syndrome:
Tightness at the ITB.
Hip abductor muscle weakness: certain gluteal muscles such as gluteus medius play a role in abducting the hip (moving it to the side) and stabilising the hip & trunk along this plane of motion when walking/running.
Increased knee internal rotation (rotating inwards). This places the ITB in a position potentially for more compression & friction at the knee.
Increased Q-angle: the angle at the knee which varies from person to person.
Increased landing forces, e.g. when running.
Weakness of hamstrings relative to quadriceps.
Genu recurvatum (knee hyperextension). A sign of instability.
Narrow step width.
Leg length discrepancy.
Altered alignment of knee, hindfoot or forefoot, e.g. flat feet.
As discussed previously, the condition is characterised by overloading the affected tissues with repetition. This could be acutely or more slowly over a longer period of time. As the ITB is compressed at 30 degrees of knee flexion, then running/walking downhill is a major contributor as it involves greater knee flexion. Another major contributor is a sudden increase in activity levels.
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There are so many potential factors that can lead to ITB syndrome occurring. At Prom Health we are well equipped to determining the various causative factors relevant for each person and creating a resolution for this complaint often quite quickly (this is because it’s non-structural, i.e. doesn’t affect the knee joint).
Diagnosis and clinical examination iliotibial band syndrome
When assessing someone we:
Palpate (feel) the area for tenderness and swelling.
Occasionally there’s paraesthesia (change of sensation).
There may be a snapping sensation with flexing and extending the knee.
We assess for the potential predisposing factors as mentioned above, such as spine, hip, ankle/foot range of motion and stability.
Perform a squat and step down test.
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One big factor that we need to consider is whether the pain is coming from the knee cap (patella) and not the ITB as they can present similarly regarding overuse and in a similar location. We have extra testing for this as well.
Treatment of iliotibial band syndrome
Initial phase
If the condition is acute, i.e. very sensitive to touch, maybe some swelling, painful with walking particularly with a bent knee.
Self-management:
Icepacks.
Oral or topical anti-inflammatories if the pain is severe.
Reduce aggravating activities such as walking/running.
Avoid knee flexion >30 degrees.
Topical creams.
Rigid taping.
Manual therapy: address restrictions of the ITB, lateral intermuscular septum, outer quadriceps, TFL, gluteus maximus, but also commonly the outer calf & hamstrings. At the insertion point we use a technique called 'friction' in which we do just that, friction the area to break down tissue. Put simply, this is a compression/friction based injury, therefore, by using manual therapy to address restrictions this reduces the load on the ITB, thus ameliorating the amount and friction and then allowing the body to heal.
Dry Needling: performed along the outer thigh to reduce the sensitivity of the nervous system, pain reduction & reduce activity of the affected muscles.
Subacute phase
When subacute, the area is either non-tender or mildly tender to touch and with activities. We begin isolated strengthening to hip muscles, calf & foot – this is dependent on individual needs. Manual therapy continues. Stretching is also a major focus.
Long-term phase
This phase is characterised by pain-free walking & general activities such as bending, gardening, etc. The area is non-tender to touch. If appropriate we begin more advanced exercises, e.g. step down & up, functional movements with a focus on control of the leg.
If you're an athlete, then return to running may actually begin with small sprints as this reduces knee flexion when landing. Return to sport is discussed on an individual basis.
The long-term aim is symmetrical strength and flexibility and meets expectations of patients anatomy/function.
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A treatment plan for iliotibial band syndrome lasts about 6 weeks but is often shorter depending on circumstances.
As mentioned at the start, both osteopaths at Prom Health, Xavier and Laura have both experienced ITB syndrome. Xavier's ITB syndrome was on his left side as a result of compensating for an old right knee issue. He also had a significant increase in activity prior to starting the hike and then obviously had a large load from carrying the hiking bag. Regarding Laura, her ITB syndrome whilst doing a marathon in New Zealand involved terrain that was far steeper and more technical than what she was able to train for. She found it challenging to replicate New Zealand mountains in South Gippsland. Both injuries resolved within weeks with appropriate management.
References
Goh LA, Chhem RK, Wang SC, Chee T. Iliotibial band thickness: sonographic measurements in asymptomatic volunteers. J Clin Ultrasound. 2003 Jun;31(5):239-44. doi: 10.1002/jcu.10168. PMID: 12767018.
Seeber GH, Wilhelm MP, Sizer PS Jr, Guthikonda A, Matthijs A, Matthijs OC, Lazovic D, Brismée JM, Gilbert KK. THE TENSILE BEHAVIORS OF THE ILIOTIBIAL BAND - A CADAVERIC INVESTIGATION. Int J Sports Phys Ther. 2020 May;15(3):451-459. PMID: 32566381; PMCID: PMC7296993.
Dommerholt, J. (2015). Manual Therapy for Musculoskeletal Pain Syndromes: an evidence- and clinical-informed approach. Churchill Livingstone.