Iliotibial Band Syndrome

Carla Stecco in her book Functional atlas of the human fascial system defined Iliotibial Tract (ITT) as a whole fascial  stocking completely encircling the thigh and is extensively connected to the lateral intermuscular septum and anchored to the lower part of the femur. The action of the ITT and its associated muscles is to flex and abduct the hip. In addition, the ITT contributes to lateral knee stabilization. The ITT also serves as a distal tendon insertion for the tensor fasciae latae and gluteus maximus muscles. Distally, the ITT is attached to the lateral condyle of the tibia and gives an oblique myofascial expansion that passes under the patella, contributing to the formation of the anterior knee retinaculum.

The iliotibial tract (ITT) connects the muscles of the pelvis with the knee. It stabilizes the knee both in extension and in partial flexion and is used constantly during walking and running. Many fibres of the gluteus maximus are inserted into the ITT and into the posterior aspect of the lateral intermuscular septum, which is continuous with the ITT. Other gluteus maximus fibres have an oblique direction and so pass over the ITT to continue into the fascia over the vastus lateralis. Fibres of the vastus lateralis also insert into the anterior aspect of the lateral intermuscular septum and merge at the knee with the anterior knee retinaculum. The ITT together with the lateral intermuscular septum coordinates the action of both the gluteus maximus and vastus lateralis (Stecco, 2014).

Iliotibial Band Syndrome (ITBS) is a common overuse injury common with runners and cyclists, especially when their training levels have recently increased. It was reported as the second most common running injury and most common reason for lateral knee pain in runners. ITBS can also be associated with court and racquet sports, strength training (especially from weight-bearing squats), and even pregnancy. Leg length differences and misalignments of the pelvis can also be contributing factors. It produces burning pain on the lateral aspect of the knee, and exacerbated by running, especially downhill
The pain is most severe when the knee is bent between 30 to 45 degrees.

It is conventionally believed that the cause of the pain is the repetitive movement of the “cabled ” ITB sliding back and forth across the outer surface of the lateral epicondyle. This mainly occurs in in 25° to 30° of knee flexion, irritating the ITB or its associated bursa during repetitive activities such as running. Conventional treatment often locates the sore spots around the condyle and perform cross-fibre friction with the aim to break down the adhesions, which will enhance fibroblast generation and encourage tissue remodelling.

However, Fairclough et al. questioned this notion that the ITB moves with respect to the lateral epicondyle during knee flexion-extension. In a study published in the Journal of Science and Medicine in Sport in 2007, they stressed that there are several basic anatomy of the ITB that had been overlooked:

(1) The ITB is not a discrete structure but a thickened part of the fascia lata which envelopes the entire thigh;

(2) It is connected to the linea aspera by an intermuscular septum and to the supracondylar region of the femur (including the epicondyle) by coarse, fibrous bands which are not pathological adhesions; and

(3) A bursa is rarely present but can be mistaken for the lateral recess of the knee.

As ITT is a whole structure, ITB cannot create frictional forces by moving forwards and backwards over the epicondyle during flexion and extension of the knee. The reciprocal tightening of the anterior and posterior portions of the ITB during knee flexion-extension creates this illusion of motion.They proposed that ITBS is caused by increased compression of the highly vascularized and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle. The pain can be related to a chronic increased tension of the ITB caused by increased tension of the TFL or gluteus maximus muscles. The authors concluded that “ITB syndrome is related to impaired function of the hip musculature and that its resolution can only be properly achieved when the biomechanics of hip muscle function are properly addressed.” Chen et al (2006) showed with MRI that gluteal contracture causes a posteromedial displacement of the ITB. The resolution of the ITBS needs to consider the biomechanics of hip muscle function.

Falvey et al. (2012) conducted an anatomical examination of the ITB on 20 embalmed cadavers. They found that ITB is a thickening of the fascia lata, it is
connected to femur along the linea aspera from the greater trochanter to, and including, the lateral epicondyle of the femur by coarse fibrous bands.
In addition, Falvey tested stretching routines for ITB, and measuring the actual lengthening of the ITB by implanting strain gauges in the cadavers’ ITB. They concluded that ITB is very resistant to stretch since it lengthened less than 0.2 percent with a maximum voluntary contraction. Thus, they challenged the idea of stretching the ITB as a treatment for ITBS. They suggested treatment of ITBS should  treat the muscular components of ITB and TFL complex. Many skeptics hailed this as the evidence that ITB is not tight, cannot be stretched, and thus putting pressure in massage or using a foam roller is a waste of time.

Willet et al. (2016) questioned the Ober test which is commonly used as an examination tool for assessment of ITB tightness. They conducted an experiment using embalmed cadavers. They refute the hypothesis that the ITB plays a role in limiting hip adduction during the Ober test and question the validity of these tests for determining ITB tightness. The study suggests that the Ober test assesses tightness of structures proximal to the hip joint, such as the gluteus medius and minimus muscles and the hip joint capsule, rather than the ITB.

Nonetheless, the pathoetiology of ITBS, whether it is a compression or friction around the lateral epicondyle, is still inconclusive. There are intrinsic as well as extrinsic factors affecting it.

Elsing et al. (2013) study examined whether the ITB moves relative to the lateral femoral epicondyle (LFE) as a function of knee flexion in both non–weight-bearing and weight-bearing positions in asymptomatic recreational runners. Sonographic evaluation of the ITB clearly showed anteroposterior motion of the ITB relative to the LFE during knee flexion-extension. The ITB does, in fact, move relative to the femur during the functional ranges of knee motion.

A study published in the Clinical Journal of Sports Medicine in 2000 by Dr. Michael Fredericson, from Stanford University, compared 24 runners with ITB syndrome with 30 healthy runners and found the injured runners have weaker hip abductors (mainly gluteus medius and minimus) than the non-injured runners. In a study in 2002 tested  the effectiveness of ITB stretches, and they found that an overhead arm extension to the common standing ITB stretch may increase average ITB length change. However, the ITB length measurement was based on the angular changes in markers on the skin. Fredericson and colleagues in 2006 proposed the following protocol for management of ITBS: “During the subacute phase emphasis is on stretching of the iliotibial band and soft tissue therapy for any myofascial restrictions. The recovery phase focuses on a series of exercises to improve hip abductor strength and integrated movement patterns. The final return to running phase is begun with an every other day program, starting with easy sprints and avoidance of hill training with a gradual increase in frequency and intensity. ”

There are still conflicting results on the effectiveness of ITB stretching for the treatment of ITBS. However Strengthening the hip abductors have been supported by research. 
Hip abductor strengthening has been shown to decrease hip adduction at foot strike and thus decrease ITBS symptoms.

Baker & Fredericson propose 3 recurring factors that influence the iliotibial band: reduced length, altered neuromuscular control, and weakness of the posterior and lateral hip musculature. In the acute phase (3 days to 1 week after the problem) Baker and Fredericson suggested myofascial treatment addressing trigger points in the biceps femoris, vastus lateralis, gluteus maximus, and tensor fasciae latae muscles. The subacute phase is marked by a reduction in acute pain and inflammation. It was suggested stretching the ITB, vastus lateralis, and  biceps femoris using a foam roller and manual therapy type stretches  to reduce the passive tension in the iliotibial band.

On Stretching the ITB, many skpetics claimed that ITB cannot be stretched, and the same is true for plantar fascia. However, treatment of plantar fasciitis involves stretching and applying high load. If plantar fascia cannot be stretched, why stretching can successfully treat plantar fasciitis? There are several studies which evaluated the effect of ITB stretching. A study from Korea using ultrasound showed that following a self-stretching routine, the thickness of ITB near the lateral femoral epicondyle changed significantly. A study from Melbourne showed 3 mins of foam rolling on the ITB produces an immediate increase in the Pain Pressure Threshold of the lower thigh in asymptomatic participants.

Watch Michael Fredericson’s Video: