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ILIOTIBIAL BAND SYNDROME




BY ALAN GJEDSTED MD



The entity known as Iliotibial Band Syndrome (hereafter, ITBS) is a relatively common malady of very active persons. In its most common form, it presents as a localized pain on the outside of the knee, made worse with extending the knee joint, especially in the last 20-30 degrees before full extension. By far, this problem is mostly seen in runners, especially long distance runners and hill runners, but athletes in other sports may also be at risk, such as racquet sports, aerobics, and cyclists.
Although knee pain is the most typical presentation of ITBS, the same condition that causes typical ITBS also can cause pain in
the hip area, known as Trochanteric Bursitis or anywhere along the entire course of the Iliotibial Band, which runs from the crest of the pelvis to below the knee, along the outside of the thigh.


What Causes ITB Syndrome?

ITBS is most frequently caused by either an excessively "tight" Iliotibial Band or from what are known as "Training Errors" - a form of repetitive trauma injury stemming from doing an activity over and over in an incorrect way. Examples of such "training errors" might include running on one side of a domed, or crowned, road, with the same leg always on the downhill side; running on a track, always in the same direction, running with a "crossover stride", that is, bringing the forward foot across the centerline when running. Running uphill is a fairly common cause. It can also occur in athletes with certain body types, such as "bow-leggedness" or when one leg is shorter than the other
or when running with shoes that are too old or worn, especially if the runner is an "Over-pronator" (more about this later).


What is the Iliotibial Band and What is it for?

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The ITB is a firm, very tough layer of tissue that connects to the outside of the pelvis bone, crosses the outside of the hip (the pointy part that you can feel (i.e. Trochanter), extends down the outside of the thigh, crossing the knee joint and attaching to the bone of the lower leg, just next to the area where the kneecap tendon attaches. A number of muscles attach to the ITB, including those muscles that help spread the legs away from each other. The pain that a tight Iliotibial Band causes, with overuse, can
range anywhere along its course, but is usually worst at the areas it crosses the bony prominences, such as at the hip, and at the thighbone (Femur), just above the knee joint itself.

Why Me?
Any of the causes listed above can contribute to pain and inflammation of the ITB. Typically, the combination of a tight ITB and repetitive injury from a training error is the culprit leading to this syndrome.

What Can I Do to Get Better?
Think of your body as always being at war against the forces of destruction and breakdown. This battle is being waged essentially all the time, all over your body. Usually, your body is the winner; it can keep up with all the destructive forces (wear and tear) that you are throwing at it. Sometimes, however, the repetitive wear will overwhelm your body's ability to keep up and you begin having inflammation, which will, ultimately, become pain. It is important to realize that the breakdown/repair cycle is always taking place and that the inflammatory reaction will have been present for some time before you experience actual pain. For this reason, it is unrealistic to believe that reversing this process can be done "overnight". Everyone, both young and old alike, must first decrease the "breakdown" part of the equation and allow the "repair" to gradually gain the upper hand again. Although the "repair" process may be somewhat slowed the older you are, the same forces are at work despite your age.


How to stop the "Breakdown":
Seems simple enough, right - just stop what you are doing that is causing the problem. But, of course, it's not quite that simple. For instance, what is it about your particular sport or activity that is the culprit? Is it running on an uneven surface? How about running on a track, the same direction every day? Running hills? Aerobic Step Class? Old shoes? The wrong shoes? Cycling with your feet in the cleats incorrectly?
Any one of these things is potential causes for ITBS, but they may not be obvious at first glance. The common thread throughout is: any exercise or activity that will "functionally" make one leg longer than the other (such as running on an uneven surface or running around a track), or an activity that will cause excessive rotation at the hip, such as running with the wrong or old shoes, running up hill, poor running "form", putting your toes in the pedal clips wrong (pigeon-toed), will cause this problem to occur over time. Remember that the pain is a relatively late sign of an ongoing irritation, so by the time you are having enough pain to interfere with your usual routine, you have had the problem for quite awhile.


The Big Six of Rehabilitation:
1.Relative Rest.
2.Anti-inflammatory Maneuvers (ice, medication).
3.Stretch and Strengthening.
4. Fix any anatomic abnormalities.
5. Gradual Return to Exercise.
6. Cross-Training/Alternative Exercise.

Let's take each of these separately:

1.Relative Rest:
This is a term that implies that you can "cut back" on your exercise routine to a point where you are able to begin healing (even though you may still have some pain) and are still able to stay active. This might mean that you decrease your running mileage or it may require that you change to a different sport or exercise while healing. An example might be a runner who develops ITBS is able to cycle without worsening the pain, still maintaining a level of fitness. Good alternative exercises would be swimming, pool aerobics or pool running, or, perhaps, Stairmaster. There are a certain number of people with this problem that may have to go so far as using crutches and a stiff knee brace that completely rests the knee, in order to get better.

2. Anti-inflammatory Maneuvers:
Use ice on the most sore and tender areas, three to four times a day, for about 15-20 minutes each time (to the point of numbness). Anti-inflammatory medicines would include Aspirin, Advil, Motrin, Alleve or Naprosyn. Be aware of the potential for stomach upset or even bleeding from any one of these



3. Stretching and Strengthening:
This is probably the most important part of your rehabilitation. If you don't do this part, or if you do it just until you are better, there is a good chance of recurrence.


Stretching:

The above link is to the important stretches that should be begun and maintained, throughout your career in sports, in order to get you better and keep you better. Do a set of stretches (after a short warm-up) before your exercise routine, whatever it may be, then again after exercise. You might consider doing them at least one more time during the day, especially when you are first starting out. The correct way to do the stretches is to take the muscle to the point of "tightness", just before pain, hold for at least 10-15 seconds (count in your head), then release. Do this two or three times for each stretch, and that is one "set". Also, see Classical ITB Stretch and
Alternate ITB Stretch.

Strengthening:

Strengthening the same muscle groups you are stretching is a must. Remember that in order to heal and prevent future injury, muscles must be both strong and elastic, or pliable. Strengthening exercises are at the end of this sheet. Another easy-to-do exercise is to use a strap or tubing (available commercially as Theraband, or you can use an old bicycle inner tube) to do the exercises. Attached, are some important strengthening exercises to begin to rid yourself of this troubling problem:
1) GLUTEUS STRENGTHENING
2) STEPUP STRENGTHENING
3)THERABAND EXERCISE

4. Fixing "Anatomic Abnormalities":

This means that you should get good shoes. Remember that running shoes are effective for somewhere between 400-500 miles, after which they loose their ability to provide good cushion and motion control; get new shoes well before you reach this point to prevent injuries. Also, correct any training errors, such as: running on domed streets (run on flat as much as possible, or at least be sure to make sure that the downhill, or "gutter" foot changes - if your runs are out and backs, go out and back on the same side of the street); running on a track (change directions of your track runs either daily or every few laps); running hills (keep the hill as flat as possible and use a shortened stride). If you know you have a difference in your leg lengths, unusual feet, bow-leggedness, or other anatomic curiosities, it is frequently worth the money to be fitted for special shoe inserts, especially if you are sure you wish to continue with running as your primary exercise. These inserts are called Orthotics, and can be obtained from Podiatrists outside of Kaiser. They are not covered under your Kaiser Benefits Plan. We can give you the name of an outside Podiatrist who provides this service. For people who are simply Over-Pronators (over rotation of the foot as goes from heel strike to pushing off) - usually a person with a flat foot, short first toe, or arches that collapse when weight is put on them - a trial of over-the--counter Arch Support/orthotics may be tried. Brand names include Flexifly, Superfeet, PFI, and Spenco; ask you doctor about where these can be obtained.


5. Gradual Return to Exercise:

Even though you may never have completely stopped your exercise routine, it is vitally important to stress that VERY GRADUAL increases in intensity or duration of exercise are important. By far the most common reason for relapse in any of the Overuse (or repetitive trauma) injuries, of which ITBS is but one, is TOO RAPID INCREASE IN EXERCISE ROUTINES. This means that if you are doing well at, say 2 miles of running a day, but you had developed the problem when you were running 5 miles a day, then as you begin to increase back up to your goal mileage, you must increase by no more than 10% a week, assuming that each increase does not cause any renewed symptoms. An example of this would be, if you were running 2 mile/day, 5 days a week (10 miles/week), then, when you were ready to increase, you would move "up" to 10 miles plus 10% (1 mile), or 11 miles a week. Stay at that level for at least a week, to assure no increase in your pain. You can see that this is a very small increment. However, it is really the only way to insure that too large a jump won't be attempted, thereby causing a return to the pre-rehab levels of pain and requiring you to start from the very beginning again.


6.Cross-train/Alternative Exercise:

As mentioned before: in order to remain fit while rehabilitating this injury, you should try to find an alternate exercise or sport which you are able to do without causing an increase in your pain. For runners, cycling, swimming, or pool running/aerobics are good alternatives; for cyclists, swimming should be okay. The object is to maintain your endurance and aerobic fitness despite a break from your usual activity. Resistance exercise (and stretching) should become a regular part of whatever regimen you do, even upon return to your preferred sport.



Are There Any Other Options?

For those persons who, despite trying everything, still continue to have limiting symptoms, or those in whom the discomfort prevents even beginning the rehabilitation regimen, it is possible to use injected Cortisone (or Cortisone-like medication) in the inflamed area, which can dramatically decrease inflammation. This should not be considered the first line of therapy in most athletes; however, because it does not address the underlying cause of the problem and using just injection without a complete rehab regimen usually leads to relapses. Injection also entails a post-injection rest from sports for at least a week.
Surgery is usually not required, except in very stubborn cases of Trochanteric Bursitis, a related condition to ITBS.




REMEMBER:

This problem did not occur overnight. It has been present, or the conditions have been present, for quite some time. It will not be healed by tomorrow or, even, next week. However, if you persist with your rehab plan and move slowly getting back to your exercise goal, you should be able to get over this problem once and for al


TROCHANTERIC BURSITIS


Special mention should be made on the related problem known as Trochanteric Bursitis.
Although related to ITBS in it's causes and the treatment, it differs in that, along with being most common in runners, it also occurs more frequently in women (due, in part, to the configuration of the woman's pelvic bones) and those who have either gained or lost a large amount of weight. It can also begin after trauma, where one falls, hitting the point of the hip. It can be an annoying, painful problem, worse with sleeping, or after sitting (especially with legs crossed) and can be severe enough to prevent normal walking.
Again, the treatment for this entity is the same as for the ITBS noted above,