Arch Supports And Iliotibial Band (ITB) Pain

A patient came in this week after being diagnosed with Iliotibial band (ITB) syndrome. The outer part of his right knee would hurt badly after running about 1.5 km. After stopping to walk, he would be able to run for a few minutes before having to stop again. 

He had been running 4-5x each week, clocking about 50 km weekly. He had just seen a sports doctor who first referred him to a podiatrist to get orthotics as he 'pronated' badly.

After getting his orthotics, he 'pronated' less according to the prodiatrist who filmed him while running on a treadmill. But, alas, his ITB/ knee pain didn't change. Since I'd treated a fellow runner he knew, he came to see me, hoping I could help him run pain free.

The ITB starts from the TFL

I've written previously about the ITB and you can read more about it here (anatomy) and here. If you look at the picture above, you can see it starts from Tensor Fascia Lata (TFL) muscle and runs down the outer thigh before finishing just at the outer part of the knee (picture below). This is usually where runners experience a sharp pain.

Also know as iliotibial tract (bottom R of pic)

Studies show that when the hip rotates medially or drop inwards, a strain is placed on the ITB . This also causes the tibia (or shin bone) to rotate inwards causing the foot to pronate (or ankle eversion). 

Researchers have attempted to correct this by changing ankle pronation to see if this might relieve the strain on the ITB.

In this published paper, 30 runners (15 males, 15 females) with no ITB insertion pain were prescribed orthotic wedges to put into their own running shoes. The wedges were 7 degrees lateral, 3 degrees lateral, no wedges, 7 degrees medial and 3 degrees medial. A total of five running trials were done.

The runners were analyzed by video motion analysis while running at their self selected running pace to calculate motion forces and ITB strain.

The orthotic wedges significantly changed ankle eversion (or pronation) angles compared to no wedges. However, the strain rates did not differ between conditions. There was no change in knee joint angles and tibial rotation under all orthotic wedge conditions. 

The researchers concluded that orthotic wedges may not change forces acting on the ITB, even though they altered foot pronation while female runners had greater strain forces acting on their ITB's potentially due to increased internal hip rotation.

It is interesting to note that the female runners demonstrated significantly greater peak ITB strain and strain rates compared to the male runners, potentially due to increased hip internal rotation (because of wider hips and pelvises for child bearing purposes). I have written at length before that for female runners, their knee pain is coming from their hips. Always treat the cause of the problem. Do not treat the pain alone.

Take home message is that even though orthotic wedges can correct your foot's pronation, it may not alter forces acting on your ITB. This means that your knee pain may not get better using orthotic wedges.

Of course any one reading this may say that these off the shelf orthotic wedges are not customized and that the subjects were all wearing different running shoes. Personally I feel that the different shoes are not an issue as these orthotic wedges used in the study did significantly change ankle pronation so they did what they were supposed to do. 

Would this then be fair to say that using orthotics to change ankle pronation or eversion angles does not seem to benefit those with ITB pain at the knee? Perhaps any podiatrists reading this would like to comment.

Reference

Day EM and Gillette JC (2019). Acute Effects Of Wedge Orthoses And Sex On Illotibial Band Strain During Overground Running In Nonfatiguing Conditions. JOSPT. 49(10): 743-750/ DOI: 10.2519/jospt.2019.8837

ITB attachments at the knee

Iliotibial Band Pain In Runners

The ITB originates from the TFL

I had a patient this week that was suffering from Iliotibial band (ITB) pain and he was so fed up with the pain that he was considering getting a steroid/ cortisone injection to get rid of the pain. He sent me an article he'd found for me to ask for my opinion.

Having previously suffered from Iliotibial band or ITB syndrome myself before, I'll naturally read any article I'd come across about the ITB.

The ITB over the Vastus Lateralis muscle

The article itself wasn't so interesting even though the authors got a good result after their intervention. The authors concluded that a steroid/ cortisone injection was effective in reducing ITB pain in runners in the first two weeks of treatment.

I'm not a fan at all when it comes to injecting steroid (or cortisone) to treat any sporting injuries. I written previously that often the cause of the problem is from the hip. For best results, you treat the cause of the problem.

As I've written previously, if you're an athlete or exercising regularly, you definitely do not want a steroid/ cortisone injection since there is a very high chance of degenerative changes in the surrounding area of the steroid injection. You can read about how my patient tore his forearm flexor tendon after repeated steroid injections.

Anyway, what intrigued me about this article was the small sample size and how long it took to recruit the runners (it took two whole years). The authors managed to recruit 45 runners but only 18 fulfilled the criteria and finished the study.

There was an attempt to have a longer follow up period, but there was too much variability in the second phase treatment of the condition. Their return to running, distance ran, rehabilitation program, change in footwear and use of orthotics etc.

Most of the eligible runners did not want to stop running during the 2-week intervention period. Exactly what I said about athletes (not wanting to rest) in my interview which you can see here. This shows the challenge of recruiting runners for research.

How about you? If you were recruited for a running research and asked to stop running for 2 weeks for the sake of research, would you comply? I'd like to hear your views.

Reference

Gunther P and Schwellung MP (2004). Local Corticosteroid Injection In Iliotibial Band Friction Syndrome In Runners: A Randomised Controlled Trial. BJSM. 38(3): 269-272. DOI: 10.1136/bjsm.2003.000283.

Latest Research On The ITB (Iliotibial Band)

Picture taken with my Canon Ixus 

Mention the ITB (or iliotibial band) and images of pain quickly crop up. IT band syndrome is a painful overuse injury usually at the lateral (or outer) portion of the knee in many runners and cyclists.

Latest research on the IT band from Daniel Lieberman's Harvard lab by his former student Carolyn Eng shows that the IT band may not function as what was formerly believed.

Another view

The ITB runs along the outer part of the thigh, originating from your Tensor Fascia Lata and Gluteus Maximus muscles just above your hip to attach just below the knee. It is made up of fascia, an elastic connective tissue found throughout our body. Fascia is a sheath of connective tissue that wraps our muscle, nerves and blood vessels. It also connects our muscles to bones.

The researchers used human cadavers to investigate how the IT band moves and stretches during walking and running. A computer model was then built to calculate the forces and strains involved and then compared to the equivalent structure in chimpanzees (published in another journal).

Previously, the IT band's primary function was believed to stabilize the hip during walking. Carolyn Eng's research suggested that the IT band actually acts like a spring, storing energy when you swing your leg back and releasing it as the leg swings forward.

This energy storage capacity is highly developed in humans, enabling it to store 15 to 20 times more energy than a comparable structure in chimpanzees.

Lieberman suggested that if we consider evolution and how humans are adapted not just for walking but running as well, then the IT band is looked at at a totally different perspective. The IT band looked like another elastic structure, similar to the Achilles tendon, and this may be important for saving energy during walking and especially running.

The researchers estimate the IT band stores about seven joules of energy during fast running compared to about the standard estimate of about 50 joules in the Achilles tendon.

The researchers hope that with this improved standing of how the IT band works, they can compare how much forces the IT band transmits in runners with and without IT band pain. This will then establish a scientific basis for treating IT band injuries.

References

Eng CM, Arnold AS, Liberman DE et al (2015). The Capacity Of The Human Iliotibal Band To Store Elastic Energy During Running. J Biomech. pii: S0021-9290 (15) 00354-1. DOI:10.1016/j.jbiomech.2015.06.017.

Eng CM, Arnold AS et al (2015). The Human Iliotibila Band Is Specialized For Elastic Energy Storage Compared With The Chimp Fascia Lata. J Exp Biol. 218(15): 2382-2393. DOI: 10.1242/jeb.117952.

Here's Carolyn Eng's (Harvard University) computer simulation of a human leg running from here.