by Hamid L. Sadri, DC, CCSP, ICSSD, CSCS, CKTP, CES, PES
Running is commonly referred to as the “Mother of All Sports”; and perhaps rightfully so. There are many great benefits that are derived from running that can help enhance just about any form of sport or physical activity one may think of, from improving cardiac output to enhancing endurance, speed and agility. Unfortunately many injuries arise from this apparently easy and common form of exercise, most of which are frequently categorized under “Repetitive Sprain/Strain Injuries” (RSI) or “Overuse Syndrome” (OS). Since both the amateur, as well as the professional athlete may experience these forms of injuries from time to time as they engage in their respective sports; in a series of articles, beginning with this one, we hope to help address some of their common forms, signs, symptoms, treatments and available remedies.
An area of the body that frequently becomes symptomatic in sports is the knee. Knee pain appears to be one of the most frequent complaints we come across in our practice. The most common condition we find in our cyclists and runners is what is called “ Iliotibial Band Syndrome ” or ITBS. This is a rather painful condition that is often experienced by both of these types of athletes and is classified as an OS. The typical pattern is an onset of gradual, and initially periodic, pain on the outside of the knee that may extend slightly above or below the knee joint or into the patellar (knee cap) region. With time and without proper treatment, the pain will become a constant diffuse feeling that can be present even with simple walking. It tends to worsen with increased physical activity, and if left untreated, can become quiet debilitating. Another sign and symptom of ITBS includes increased knee pain when running downhill (not necessarily present while running uphill). The pain is usually more pronounced during the swing forward phase of the running gate. The athlete may experience a repeated snapping on the outside of their knee while walking or running.
To understand how this condition develops and how it may be treated, we must first have a basic understanding of the regional anatomy and the various structures that can contribute to the development or resolution of this symptom. The Iliotibial Band is a rather dense fascial layer of tissue that runs on the outside of the hip and thigh. It extends from the top of the pelvis (Iliac crest) to just below the knee joint where it attaches mostly to the outside of the upper leg (the Tibia). If you were to extend your leg out while seated and then run your fingers back and forth just above the knee joint on the outside of the thigh, you would be able to easily feel the lower portion of your ITB. Directly beneath the ITB runs a wide and long muscle called the Vastus Lateralis. In the upper part of the band, around the pelvic region, there are 2 other muscles that also contribute fascial fibers that run into the ITB. These are the Gluteus Maximus and the Tensor Fascia Lata (TFL).
Although diagnosing this condition can be rather easy, the cause could be difficult to find.Many a clinician is unsuccessful in proper treatment and resolution of ITBS, simply because they fail to evaluate and consider all the different possibilities that could have resulted in this syndrome. Some of the most common causes of ITBS include anatomical elements such as wider or thicker IT bands, increased angles between the leg and the thigh, larger than average bony structures of the lower thigh (the lateral femoral condyle), and large amount of leg length differences. These contributing factors are among the most difficult, and at times, impossible to resolve conservatively.Other contributing biomechanical elements can include over/under pronation of the foot, weak gluteal, quadriceps or hamstring muscles, misalignment and or biomechanical distortions of the foot, ankle, knee, hip or sacroiliac joints, tight and under stretched IT bands, tight and comparatively over developed hip adductor muscles, Anterior Cruciate Ligament (ACL) laxity, and rotational instability of the knee joint. These are generally conditions that if detected correctly, can be very effectively treated through conservative care and management.
Other factors involved include over training, sudden and improper increase of length, duration or distance of activity, poor shock absorption or inappropriate design of shoes, incorrectly fitted foot gear, improperly adjusted bicycle seats or pedals, worn out shoes, running on uneven surfaces, excessive running on hills and or hard surfaces. Many of these factors can be identified by the athlete and if addressed in time can help prevent the development of ITBS.
Some of the other common ailments that could present with similar or overlapping symptoms of ITBS can include, osteoarthritis of the knee, meniscal injuries, strain or tendonitis of the hamstrings or quadriceps, sprain injuries to various ligamentous structures of the knee (ACL, PCL, MCL, or LCL), chondromalacia patella, strain of the Popletius muscle (this is a small but very functionally important muscle located just behind and below the knee). However, properly diagnosing the condition is not enough in treating this common problem. As obvious from the above description of various causative factors, the astute clinician must determine the true underlying cause (many of times, multiple factors) if he or she is to help resolve the symptom correctly and permanently. The treatment protocol often involves (and always should include) a postural and gait analysis, and a complete examination of the structures and biomechanics of the foot, ankle, knee, hip and the pelvis. Tissue texture, condition, elasticity, and strength of various muscles, tendons and ligaments, (especially the IT band itself) as mentioned above, must be evaluated. Other necessary diagnostic testing (X-rays, MRI’s, etc.) must be performed if needed to rule out other possible causes of the pain.
One of the first steps of treatment is a reduction of the contributing physical activity. Various therapeutic modalities such as ultrasound, ice, iontophoresis, phonophoresis, interferential current, or TENS could be effective.Proper combination of targeted and specific stretching and or strengthening exercises of the hamstrings, TFL, quadriceps, and or the gluteal muscles must be done. Use of supports such as Cho-pat straps may be helpful and necessary. The need for foot orthotics must be evaluated and correctly prescribed. An over-correction by an improperly fitted orthotic can be just as bad as, if not worse than, not having one at all.
These are the typical treatment approaches utilized by most clinicians and therapists. What we have found is that overuse injuries such as ITBS, very often result in the formation of adhesions within and in between some of the soft tissues mentioned above. If these adhesions are not resolved effectively and early on in the treatment process, the outcome may be less than desirable for the patient. Many forms of soft tissue techniques are available and offered by various therapists. Massage, cross fiber friction, rolfing, myofascial release, and manual trigger point therapy are some of the commonly used options. However, in our years of practice we have found 2 methods of soft tissue treatment techniques to be most effective and unlike any other approach in soft tissue care. These are Active Release Technique (A.R.T.) and Graston Technique. We have used these two methods of treatment in conjunction with some of the other therapeutic modalities mentioned above and have been able to obtain results much faster and far superior to any other form of soft tissue treatment.
If the properly administered conservative treatment and therapeutic approach is not sufficient in resolving ITBS, other more invasive treatments are available. These include oral anti-inflammatory medications or steroid injections, and may often be administered along with the above referenced therapeutic treatments.At times, although rare, the conservative treatment approach may fail, at which time a surgical release of the IT band may be necessary. Although it is, and should be, a last and final resort, this is typically a very successful procedure and may include the release of the posterior part of the IT band, osteotomy of the lateral femoral condyle, or bursectomy.
Whatever the cause of the pain may be, it should be kept in mind that generally the longer the patient waits to begin treatment, the more difficult it becomes to resolve the issue effectively and rapidly.
Dr. Sadri has been practicing in Decatur, GA for 25 years and specializes in athletic injuries and rehab. The clinic, 1st Choice Sports Rehab Center, was named “The Best Sports Injury Center in the Southeast” by Competitor Magazine. To subscribe to our newsletter click here. To schedule an evaluation, call 404-377-0011.