No Need To Stretch Or Foam Roll Your ITB?

You are a runner and you haven't been able to run more than 2 km before a sharp pain in your outer knee reduces your run to a hobble. Resting, icing and changing your running shoes made no difference. The sports doctor you saw just diagnosed you with the dreaded Iliotibial Band Syndrome (ITBS). He tells you that you need to stretch your Iliotibial band (ITB) and use a foam roller.

Sounds familiar? Well, this latest published paper on the ITB by Paul Giesler (2020) challenges common treatment approaches of stretching and massaging the ITB. Basically, he says that you do not want to stretch or foam roll your ITB.

Attachments of ITB at L knee

I've written about the ITB before in a few different posts. Except for Daniel Liberman and Carolyn Eng's study, most other articles seem to suggest that the ITB causes pain via a 'friction syndrome'. This is thought to be due to the ITB rubbing to and fro over Gerdy's tubercle on the outer shin bone while running due to hip weakness. 

Treatment is normally targeted at stretching the ITB (to reduce friction). Doctors will often suggest a steroid injection to reduce 'inflammation' (in the bursa) on the outer knee.  Giesler (2020) however,  suggested that ITB pathology is more likely to involve compression of sensitive structures beneath the ITB rather than friction.

also know as Iliotibial tract (ITT)

Since the ITB is a really broad, strong and complex structure with many attachments (picture above) along the hip, thigh and around the knee, it can provide stability for both the hip and knee. Like I wrote before, the ITB is actually thought to function like our Achilles tendon. To store and release energy like a spring. Therefore you cannot and would not want to stretch a spring. A coiled spring can release energy much better than a spring that is stretched out.

From Carolyn Eng's running simulation 

Hence the need to treat the cause of the problem rather than just treating the pain over the outer knee. Hip strength and control thus thought to be key in causing ITBS, especially weakness in hip increased hip adduction (dropping of the hip inwards) during loading. 

Runner on L has increased hip adduction

In runners/ patients with excessive hip adduction while running, progressive rehab and addressing potential causes should be adapted for individual runners, especially while running downhill and during longer runs. I've written on this topic specifically, you can read that article here.

So treatment should be to calm the symptoms (knee pain) and treat the cause. We don't get you to stretch your ITB or use the foam roller in our clinics, come see us if you want to run pain free.

The Paul Geisler (2020) article is free, click on the link under references if you want to read it.

References

Bramah C, Preece SJ Nimh G et al (2018). Is There A Pathological Gait Associated With Common Soft Tissue Running Injuries? AJSM. 46(12): 3023-3031. DOI: 10.1177/0363546518793657

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.

Geisler PR (2020). Iliotibial Band Pathology: Synthesizing The Available Evidence For Clinical Progress. J Ath Trg. DOI: 10.4085/JAT0548-19

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.

Is Your Running Style Causing Your Running Injury?

How's my running gait?

I saw a patient yesterday who was training for the upcoming Singapore marathon. He started having knee and heel pain after doing a long run of 22 km over the weekend. Upon assessment, he definitely demonstrated a greater contralateral (or opposite) pelvic drop (CPD), indicating Gluteus Medius muscle weakness.

Picture A- Injured runner with CPD and right hip adduction 

Last week we discussed whether doing clam shell exercises was still relevant for someone with Gluteus Medius muscle weakness. Turn's out that this week's post is related to that.

The referenced study (Bramah et al, 2018) investigated and identified certain faulty running gait patterns that contribute to running injuries. In all, 108 runners were studied, including 72 injured runners and 36 healthy runners in the control group matched for age, height and weight.

None of the injured runners received any prior treatment for their injury. Those with an increase with more than 30 percent in training volume were also excluded from the study. The control group of runners ran at least 30 miles (or 48 km) a week.

The injuries the injured runners had were patella femoral pain (PFP), Iliotibial Band Syndrome (ITBS), Medial Tibial Stress Syndrome (MTSS or shin splints) and Achilles Tendinopathy (AT). The injuries were selected as they are most prevalent among runners.

All the injured runners showed a greater contralateral (or opposite) pelvic drop (CPD), demonstrating Gluteus Medius muscle weakness. They had a more extended knee and dorsiflexed ankle (heel striking) at initial contact and a forward trunk lean at the midstance phase of running. These patterns were consistent across each of the four injured groups.

Contralateral pelvic drop

CPD was found to be the most important variable predicting whether the study participants were healthy or injured. For every 1 degree increase in pelvic drop, there was a 80 percent increase in the odds of getting injured.

Injured runner (L) heel striking, forward trunk lean vs normal

Those who had more knee extension makes the patella (kneecap) more vulnerable to lateral tilting and displacement. This may affect knee joint contact areas and increase stress when the foot strikes the ground. If a runner heel strikes with the knee extended, their center of mass is further away from their foot. This leads to an increase in knee joint loading and a increase "braking" forces (imagine applying brakes on while you're running).

Those with a forward trunk lean may have weakness around the back and gluteal muscles as shown by previous studies. The injured runners with PFP and ITB problems had more hip adduction than other runners. More female runners were also found to more hip adduction compared to male runners.

So make sure your Gluteus Medius muscles are strong enough so that you will be less likely to have a running injury.


References

Bramah C, Preece SJ Nimh G et al (2018). Is There A Pathological Gait Associated With Common Soft Tissue Running Injuries? AJSM. 46(12): 3023-3031. DOI: 10.1177/0363546518793657

Lessi GC, Dos Santos AF et al (2017). Effects Of Fatigue On Lower Limb, Pelvis And Trunk Kinematics And Muscle Activation. J Electrom Kinesiol. 32: 9-14

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.

Ladies, Your Knee Pain May Be Coming From Your Hips

How many of you ladies have knee pain? Well, you may be interested in this then. I have seen quite a few women runners/ triathletes the last couple of weeks, both elite and recreational with knee pain in the clinic. And guess what? Majority of my patients knee pain came as a result of weakness in the hips. Yes, some of them do have contributing factors coming from the knee itself, but the main cause was the hip weakness. So the hip weakness basically led to knee pain.

Well, you do know that at Physio and Sports Solutions we are really good at treating the cause of your pain rather than just treating the pain itself. So besides treating the patients' knee pain, the main thing was to explain the rationale of the treatment plan to them and then teach them how to specifically strengthen the hip muscles.

The strange thing is I've actually noticed this trend quite a while earlier from treating previous patients. So I was really pleased to find an article that was published earlier this year that confirms what I thought.

The study had 19 female runners with knee pain and a separate control group of another 19 female runners as well without knee pain. The group of women with knee pain had greater average hip internal rotation range and reduced hip muscle strength compared to the other group.

The authors concluded that it is the abnormal hip mechanics and decrease strength levels rather than the difference in hip shape and structure of women (as compared to men) that caused their knee pain.

So ladies, if your knees are causing you grief while running, please come in and see us and we will treat the cause of it to prevent it from coming back. And then you can run, pain free of course.


Reference

Souza RB and Powers CM (2009). Predictors of Hip Internal Rotation during Running: An Evaluation of Hip Strength and Femoral Structure in Women With and Without Patellofemoral Pain. Am J Sp Med. 37(3):579-587.