Iliotibial Band Syndrome

Iliotibial band syndrome is so named due to the difficulty in determining whether that specific tissue is the cause of a person's knee pain, lateral leg pain and or lateral (outer) hip pain. One can better understand the challenges of identifying and treating this problem just by understanding more about the anatomy and function of the ITB and its surrounding muscle tissues.

The iliotibial band (ITB) is a formation of dense connective tissue that originates at the lateral hip/femur in the area of the large bony prominence at the lateral hip known as the greater trochanter and descends down the lateral thigh to an area of the lateral tibia known as Gertie's tubercle. It serves to act as an attachment for several muscles including the tensor fascia lata, gluteus medius, gluteus minimus, gluteus maximus, and some authors have noted that the blend of fascia behind the greater trochanter that connects some of the hip external rotators is attached to a portion of the ITB. These broadly attached structures means the ITB helps to stabilize the lateral hip during walking and running, and based on its lower attachment or insertion into the lateral tibia just below the knee, it functionally connects the knee to the hip.

In a classic gait study, Inman showed clearly that the ITB, based on its attachment to the tensor fascia lata functions as a hip internal rotator. Hence, many ITB stretches you may learn should include hip external rotation, which would mean the foot on the side you want to stretch should be pointed outward with toes away from your body. Based also on the attachments, the ITB is shortened during hip abduction, or moving the hip and leg away from the midline of the body. Again, the opposite motion, hip adduction, or movement of the leg and hip toward or across the midline of the body stretches the ITB.

The lower fibers of the ITB blend into the lateral patellar ligament and the fibers of the lateral retinaculum. Both of these structures attach to the outer border of the knee cap (patella) and run horizontally to connect to the lateral femur. There are matching fibers on the medial side (inside) of the patella but the outer fibers are 4 times thicker and much tighter as shown originally by Perry, et al in a classic anatomy study. This blending attachment means the ITB and lateral gluteal muscles that can cause ITB tightness can have an action on the patella to create lateral patellar forces. These lateral knee cap forces can cause abnormal contact pressures at the joint connection between the knee cap and the surface of the thigh or femur that the knee cap contacts, called the trochlear groove. Over time this can result in arthritic changes at the patellofemoral joint (PFJ), or if the forces are dramatic then the knee cap can move partially out of the PFJ causing what is called a subluxated patella. If the forces are extreme then the worst potential result may occur which would be a lateral patellar dislocation.

There are many factors that need to be present in order to cause a lateral patellar dislocation, but one of them is a broad attachment of the lateral quadriceps (vastus lateralis) that attaches to the lower ITB. In fact, an arthroscopic surgery to diminish these lateral knee cap forces is to dissect the ITB away from the vastus lateralis and to cut a portion of that muscle away from the lower attachment on the knee cap. Fibers of the lateral retinaculum are also cut so there is no tight lateral pull of the knee cap in the PFJ.

Due to the descending vertical fibers of the ITB and the fact that the ITB crosses the knee joint, some people get a fierce lateral knee pain that is caused by the ITB as it frictions back and forth with every step of running and walking. Some people have a lot of ITB tightness combined with a prominent lateral surface of the lateral femoral condyle, which causes what is known as distal IT Band Friction Syndrome (ITBFS). People with genu valgus, also known as being knock-kneed, and varus or being bowed-legged are also susceptible to ITBFS. ITBFS requires the affected person to stop running for a short while and to lower the inflammation in the painful area. Strategies may include: ice, anti-inflammatory medication, modalities such as iontophoresis, phonophoresis, are effective. Typically a cortisone injection into the area will be a very rapid source of relief and should be a first line consideration for the ardent and addicted runner. Stretching and manual soft tissue mobilization should be a consideration but the professional treating you needs to understand well which stage of inflammation and recovery you are in so as not to promote worsening inflammation with manual soft tissue massage or mobilization techniques or with stretching.

Another component of ITB syndrome is lateral hip pain. This is almost directly over the greater trochanter and the ITB can be so tight that people with this problem feel a "popping or snapping" as the ITB frictions and moves over the prominent greater trochanter. In this condition, the lateral gluteal muscles are very tight as well. This can feel so aggressive to people that they come into the office saying, "My hip is dislocating!" This problem will many times be diagnosed as trochanteric bursitis as the surrounding bursa tissue, which is supposed to act as a low friction lubricating structure starts to get inflamed and become a source of increasing friction and pain. This problem, if identified early enough and dealt with properly and expediently by the patient, responds well to anti-inflammatory drugs, cortisone injections and stretching of several gluteal muscles. Because of the many muscles that attach to this area as mentioned earlier, the patient dealing with this problem needs to identify many different positions to stretch in. One position alone only stretches one section of one of these muscles and does not adequately affect the many areas that need to be addressed.

Less common is the person who feels a mid to lower thigh pain over the ITB and sometimes over the lateral quadriceps as well. This person may have not only ITB pain but also vastus lateralis pain and tightness and tends to respond well to lateral quadriceps stretching and ITB stretching and a variety of physical therapy modalities and soft tissue mobilization.

Because the ITB is a hip internal rotator, each condition mentioned above can be negatively impacted by over-pronation of the feet. Over-pronation results in hip internal rotation. Again, the ITB and associated tissues are shorter and tighter when they are internally rotated at the hip. The tighter this entire lateral hip and knee complex is, the more the opportunity for each of the conditions mentioned above.

Other factors, as mentioned briefly earlier, that may play large roles in ITB syndrome would be a lot of valgus at the knees. This is more common in females but not exclusive to females. The way to identify this is basically to notice if one has what is typically considered "knocked knees." This results in forces that produce a lateral pull on the knee caps and again if the person with knocked knees has over-pronation and hip internal rotation then tightness to the gluteals and ITB may put them over the proverbial edge resulting in pain and inflammation.

Although this short description of ITB syndrome addresses many components of the problem, it by no means is an inclusive addressing of the topic. ITB syndrome is a very complex problem with potential implications at the hips, buttocks, knees, feet and even the patellofemoral joints. There are many reasons why a person will struggle with this problem based on body type, biomechanical shapes at many joints and bones and tightness of soft tissues. I believe it is fine to try to deal with the above type of complaints for a short while as a person attempts to address these factors and some possible solutions to the problems but most health care professionals who deal with these problems know, not addressing them properly and early enough can result in a tremendously difficult path of resolution.

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