Iliotibial (IT) Band Syndrome
This is a summary excerpt of the article: Geisler PR. Current Clinical Concepts: Synthesizing the Available Evidence for Improved Clinical Outcomes in Iliotibial Band Impingement Syndrome. Journal of Athletic Training (Allen Press). 2021;56(8):805-815.
The frequency and overall incidence of iliotibial (IT) band syndrome has been reported to range between 12% and 52% in habitual runners and 1% and 5% in military recruits, and this condition is known to account for 1.6% to 52% of all knee injuries. IT band syndrome has been described as one of the most common overuse injuries of the lower extremity in female soccer, basketball, and field hockey athletes. It has been also commonly observed in road cyclists and rowing athletes.
In 1958, Kaplan described the IT band as connecting the ilia (pelvis) to the tibia (leg); running from the iliac crest, anterior ilium and anterior-superior iliac spine; and fusing the tensor faccia ale and gluteus Maximus (GM) muscles into what he called the deltoid of the hip and inserting distally on the lines aspera and what he termed the tubercle of Gerdy. By classification, the IT band is part fascial thickening, part ligament, and part tendon. By architecture, it receives most of the GM muscle fibers and all of the tensor fascia later fibers. By function, it is still an enigmatic structure to many clinicians.
Given that the IT band is largely fascial tissue, it demonstrates an enormous ability to adapt to and transfer mechanical stress, particularly repetitive forces. The IT band is also highly innervated and capable of transmitting sensation and tension. We are the only animals to have the IT band, which are not present at birth in humans. As we begin walking, the IT band develops slowly in response to th bipedal stresses of locomotion and weight bearing, providing hip stabilization for walking running, and single-legged landing and hopping. Formed by the triangular union of the GM and tensor fascia latae muscles with the distally extending IT band, the hip's deltoid complex has a more critical and evident function during closed chain activities than simple open chain hip abduction reveals. The hip's deltoid complex more frequently acts to eccentrically stabilize the femur and tibiofemoral joints during the critical force absorption associated with walking and running stance and landing mechanics.
Renne first described IT band syndrome in 1975 and hypothesized the the IT band rolls over the lateral femoral epicondyle and perhaps events apex of the Gerdy tubercle with repetitive flexion and extension of the tibiofemoral joint (Figure 1).
More recent studies revealed that 1) the IT band does not roll over the femoral epicondyle because of firm fascia later anchors, 2) changing tensions in the anterior and posterior fibers of the IT band during flexion and extension create an illusion of movement, and 3) instead of a subtendinous bursa, a highly innervated fat pad is located deep to the IT band. Other studies also reported that the IT band plays a pivotal role in patellofemoral, tibial rotation, and anterior displacement stability.
For years, clinicians have used the Ober test as a direct measure of IT band flexibility restrictions and to confirm a primary risk factor for IT band syndrome. However, it has been demonstrated that the IT band does not limit hip adduction range of motion; rather, the gluteus medius and minimus muscles and joint capsule of the hip are responsible for limiting passive femoral-adduction motion.
Emerging fascial research informs us that the IT band cannot, in fact, be stretched to any appreciable level, even if it is tight. In other words, if a positive Ober test finding resulted from regional restrictions in the hip or thigh, then potentially the proximal muscles such as glutes, tensor fascia latae, quadrates lumborum, and etc. potentially need to be stretched and the hip joint capsule should be mobilized.
"Why do some people have IT band syndrome and yet others do not?" "What is the precise etiopathology in those runners, cyclists, and rowers who have IT band pain due to repetitive knee flexion-extension motions?"
In one study, endurance runners with IT band syndrome also exhibited ipsilateral hip abduction weakness and their symptoms improved by strengthening the hip abductor muscles. In a prospective study, researchers found that IT band-related pain was linked to peak hip adduction and knee internal rotation moments during running and suggested that treatment interventions for IT band syndrome should focus on improving motor control of the stance limb during the energy-absorption phase of gait.
The functional utility of humans' single-legged stance phase is to absorb body weight and ground reaction forces through declarative muscle action (eccentric contractions). Exaggerated or excessive multi-planar joint motions in the lower extremity indicate that the IT band in some knees is in a potential impingement zone for a longer time, increasing the strain rate in the IT band of femurs that drift out of the sagittal plane. Over an extended run, fatigue progresses and slowly decreases the ability of the proximal hip muscle to effectively absorb the high-energy loads produced in the ipsilateral lower extremity, leading to subtle and progressive degrees of dynamic vagus-rotational drift of the tibiofemoral joint.
Quite simply, the deltoid of the lower extremity, or the proximal muscles that fuse into the IT band, along with the gluteus medius and minimus and piriformis muscles, need to work constantly to avert problematic degrees of femoral adduction and internal rotation to prevent IT band fat pad impingement from occurring every time the foot hits the ground.
Clinicians should also make sure to assess the alignment and control of the pelvis during a patient's meaningful tasks such as standing, squatting, single limb standing, and forward striding, since poor pelvis control, for example, excessive rotation in the transverse plane, is frequently associated with inhibition of the hip muscles and development of functional valgum during closed kinetic chain tasks.
In summary, stretching and deep friction massage of the distal IT band should not be included in the intervention plan for IT band syndrome. A focused and progressive neuromuscular training program that starts with low-load, open chain, non-weight bearing exercises should progress to more demanding, closed chain, weight-bearing exercises to correct biomechanics flaws and increase muscular endurance within the lumbopelvic and hip complex.
I hope you find this summary helpful you as you strive to learn how recover from injuries. If you are suffering from IT band syndrome and are seeking for treatment, please contact us or your local physical therapists.
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Chang-Min (Skye) Lee, PT, DPT, MS, OCS, COMT 8000 Locust Mill Street Suite P Ellicott City, MD 21043 (667) 309-5610 https://www.skyephysiotherapy.com https://www.instagram.com/skye_physiotherapy/ https://www.facebook.com/SkyePhysiotherapy/