Itbs article

Iliotibial Band Friction Syndrome (ITBS)

By Ben Ward APA Sports Physiotherapist Level 2 Cycling Coach ITBS is a common lower limb overuse injury and few triathletes would be unaware of the its existence of ITBS (those who haven't had it almost certainly know someone who has). This article will outline what ITBS is, possible contributing factors and finally (and most importantly), what can be done to treat and/or prevent this condition.

What is ITBS? ITBS occurs as a result of impingement of the iliotibial band (ITB) onto the lateral femoral epicondyle (LE) of the knee. The ITB is a thick band of connective tissue arising from the brim of the pelvis that runs down the outside of the thigh and attaches to the upper tibia after throwing off connections to the LE and patella. It is not a discrete band as commonly depicted in anatomical illustrations but is rather a thickening of the fascia lata, the fascia which envelops the lower limb. At the level of the pelvis the ITB receives attachments from two muscles, the tensor fascia latae (TFL) and gluteus maximus (GM) - see figure 1.

There is conflicting evidence in the literature as to whether ITBS is a true friction syndrome or more the result of tissue compression but this debate is largely academic this distinction does not change the management. During running or cycling the ITB impinges on the LE as the line of force through the ITB crosses from in front to behind the LE as the knee bends (and vice versa as it straightens). The point of impingement occurs at approximately 30º of knee bend and if there is enough tension in the ITB combined with sufficient repetition then the tissues interposed between the ITB and bone become irritated and inflamed.

Figure 1 – Anatomy of the ITB Potential causative factors Like most overuse injuries, the cause of ITBS is often multifactorial and for an optimal outcome all modifiable contributing factors must be addressed. Common contributing factors are as follows: • Training error ◦ excessive volume/intensity or sudden change in volume/intensity ◦ too much downhill running ◦ consistently running on same side of road (creates an effective leg length discrepancy due to camber of road surface) • Equipment factors ◦ worn or inappropriate footwear ◦ incorrect bike fit

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Biomechanical/physical factors ◦ either extreme of high or flat foot arches (excessively supinated or pronated) ◦ excessive inward rotation of the knee during stance phase ◦ bow legs ◦ leg length discrepancy ◦ tight ITB and/or overactivity of TFL or upper GM ◦ weak hip abductor muscles and deep hip rotators leading to hip drop and excessive inward rotation of knee (see figure 2 - note asymmetry in hip angle) ◦ hypertrophied lateral quadriceps (increases tension on ITB by pushing up underneath) ◦ poor running technique ◦ poor pedaling technique

From a clinical perspective, training error combined with hip muscle weakness tends to be the most consistent finding with variable contributions from other factors. In triathletes it is not uncommon for errors in bike setup to cause muscle imbalances that cause ITBS to manifest in the run (even if cycling is pain free).

Management of ITBS As mentioned above, to effectively treat ITBS and subsequently prevent its recurrence, all modifiable contributing factors should be addressed. A typical rehabilitation program for a triathlete may involve the following: • Training modification • Ice and topical anti-inflammatories • Assess bike setup and adjust if required • Manual therapy (massage, trigger point releases etc) • Taping to facilitate awareness of pelvic and thigh position • Hip abductor and rotator strengthening • Neuromuscular retraining to help control lower limb motion • Gait re-education and/or pedaling technique correction • Review footwear – refer to podiatrist for further advice or othotics if indicated A typical rehabilitation program takes approximately 6-weeks but due to individual differences this time-frame can be quite variable. A less intensive strength maintenance program is often required to keep the condition at bay in the long term. For recalcitrant cases referral to a sports physician may be warranted and where a high quality conservative management program fails to relieve symptoms referral to an orthopaedic surgeon may be necessary.

Case Study Figures 2 and 3 below show the effects of a 4-week strengthening and neuromuscular retraining program in a distance runner with left ITBS. Note the improved hip angle on the left in figure 3 compared to figure 2. Of significance is the fact that the runner was fresh for the video taken before treatment whereas the video taken after treatment was done within 30mins of him finishing a 2hr40min run in which he remained pain free. In this case lateral hip taping to increase awareness of the abnormal pelvic drop during running was key to translating improvements in strength into improvements in function.

Figure 2 – Before treatment

Figure 3 – After treatment

How can I prevent ITBS? The best way to prevent ITBS is to avoid the training errors listed above (appropriate training prescribed by an experienced coach can help avoid many problems). Pre-season screening conducted by a suitably qualified professional such as a sports physiotherapist can also assist by identifying key physical and biomechanical areas for improvement so that an individualised prophylactic management program can be implemented to reduce your risk of ITBS (and other injuries). Once the competitive season is over the off-season is a great time to engage in a remedial strength and flexibility program to iron out all the muscle imbalances accumulated throughout the year. Getting professional advice on footwear and rotating your running shoes throughout the season is also advisable.

For treatment or further advice regarding ITBS call Performance Podiatry and Physiotherapy on 38464800 or email physio@performancepodiatry.com.au.