Iliotibial Band Syndrome (ITB) Knee Pain Sioux City
IT band (Iliotibial band) Friction Syndrome and Treatment
Iliotibial (IT) Band Syndrome is a common injury among runners and triathletes. Eventually, running’s pounding miles overwhelms the tendon on the side of the knee creating dull or sharp stabbing pain. Initially the knee and leg feels tight and becomes increasingly sore. As the injury worsens, the pain increases and eventually stops a runner in his or her tracks.
The IT band is a large sheath of tissue, called an aponeurosis. The tough group of connective tissue fibers runs on the outside of the quadriceps and inserts on the lateral tibia (outside of the knee). The tensor fascia lata and gluteal muscles attach to the top part of it in the upper leg. The tensor fascia lata starts on the front aspect of the pelvis and inserts on the front of the aponeurosis, while the gluteal muscle starts in the back of the pelvis and inserts on the back of IT band. These muscles help stabilize the hip during walking and running. The wide aponeurosis becomes a narrower, rope-like tendon near the knee as it crosses the side of the femoral epicondyle. As the iliotibial band attaches to the tibia, its rope-like structure spreads out to a wide attachment site.
The muscles work to pull and balance on the IT band which keeps the “hip and knee from wobbling side to side.” Hip and knee stabilization is very important to running efficiency and speed. When the muscle hip stabilizers fatigue they are unable to contract with enough force to stabilize the lateral movements of the knee through the IT band.
With increased muscle fatigue the knee “wobbles” even more, creating strain on the bottom part of the tendon that attaches to the knee. The bottom part of the IT band tendon absorbs a significant amount of force when running. As the knee wobbles inward, or internally rotates, the strain is increased. As the run continues, the strain on the knee continues to increase with each mile, leading to micro tearing of the tendon and tissue damage. The chronic repetitive stress and accumulation of microtears lead to larger tears, sprains, inflammation, and pain.
Iliotibial band friction syndrome is a condition that keeps people from running or finishing their race. A mild or moderate injury feels stiff and sore at the beginning of the run, but eventually disappears. A few miles later knee stiffness and soreness begins and increases throughout the race with increased tendon damage and inflammation. A dull ache becomes a sharp and stabbing pain. Eventually the body will stop you from continuing to damage the tendon by making the pain unbearable to walk on, let alone run. It becomes very tender to touch the outside of the knee, and every runner can cause sharp pain by rubbing or putting more pressure on the IT band tendon insertion or outside of the knee.
Causes of Runner’s Knee
Runners and triathletes often experience iliotibial band friction syndrome with increased training mileage or volume, especially as they near peak training volume. Training plans increase weekly milage and volume throughout the plan. Near the end of training, the ramp up increases the mileage beyond a runner’s previous weekly high. The increased training is challenging the muscles, tendons, ligaments, and joints beyond their structural limits.
Athletes have most commonly felt IT band symptoms when ramping up for their event, such as moving from a 5K to a 10K or from a half marathon to a full marathon. People describe chronic runner’s knee symptoms whenever they reach a certain distance on long runs. They come into the clinic trying to prevent the knee pain from developing in this training cycle because they are very concerned it will prevent them from reaching their marathon goal.
Lateral knee pain is more likely to develop on uneven or hard surfaces that place more stress on the knee stabilizers. Rocky trails or hard roads with a side slant require more strength and endurance of the hip and knee stabilizers. The more difficult roads fatigue the muscles and create tearing in the IT band tendon insertion at the knee. A nice, soft, smooth trail is easier to run on and does not challenge the stabilizers like a rocky trail. Running 10 miles on a canal or lake trail is not as demanding on the ankle, knee, and hip stabilizer muscles as six miles on a rocky up-and-down mountain trail. Variations of terrain, rocks, tree roots, inclines, and declines wear out and fatigue the muscles faster, which increases the likelihood of micro tears, sprains, and strains. Likewise, running on a road with a slight curve near the curb keeps the ankle slightly inverted and increases the forces on the lateral knee and IT band. Runners who always run on one side of a road often experience pain on the outside of the knee.
Diagnosing Iliotibial Band Friction Syndrome
Your physician or chiropractor may order x-rays or an MRI to evaluate the knee bone, muscles, tendons, and ligaments. Advanced imaging may be needed if the examination of the knee reveals possible internal cartilage or joint damage. If the exam does not indicate any internal damage, your provider may pursue a trial course of treatment for ITB, and if you do not improve as expected then order the tests.
Differential diagnoses may include patellofemoral pain syndrome, patellar tendinitis, knee meniscus tears, quadriceps tendinitis, bursitis, stress fractures, hip labral tears, and low back injuries. Functional strength testing will be performed to evaluate stabilizer hip and knee strength and endurance, and appropriate strengthening exercises will be given based on weakness.
Home Therapies for Treatment and Prevention
Ice is your friend. When in doubt ice for 15 minutes, then remove the ice for 15 minutes. Repeat this process as many times a day as possible to decrease pain and inflammation. Icing at home will reduce your pain and speed your healing. Some is good and more is better.
IT band braces and bands are often recommended to reduce the stress on the knee tendons and enhance healing. Glute medius, tensor fascia lata, quadricep, hamstring, and calf stretching is just as important as strengthening exercises. Foam rolling can be used to decrease muscle spasms and trigger points in the leg muscles. Over-the-counter NSAIDs are not substitutes for stretching and strengthening exercises. Some people mistakenly think foam rollers are a substitute for stretching or massage therapy. Foam rollers do help increase blood flow and relax overworked muscles, but they do not break up scar tissue or fascial adhesions.
Many runners need to have their running shoes evaluated. The wear patterns on the rubber soles will show how a person runs. Certain shoes can help reduce over pronation of the foot, which creates internal rotation of the knee and hip. A more supportive shoe can help keep the foot and knee neutral. Likewise, some runners are in shoes that have too much support, which keeps them on the outside of the shoe and actually places extra stress on the IT band. This is common when a runner receives an orthotic and then uses it in a supportive shoes. Not all running shoes are equal. A quality running store can help get you in the right shoes for your running gait to reduce tendon injuries.
Medical Treatment for Knee Pain
Your physician or sports medicine doctor may recommend over the counter or prescription anti-inflammatory medications. Some athletes respond to analgesic creams to relieve pain and inflammation. Cortisone injections may be utilized in some cases for pain and inflammation, especially when trying to aggressively treat the injury. Depending on your other symptoms, a referral might be considered for a foot and ankle specialist or orthopedic surgeon. Surgery is rarely performed for knee tendonitis injuries, but some patients develop chronic knee tendinitis as the body attempts to compensate for internal joint meniscus tears.
Conservative Treatment Options for Iliotibial Band Friction Syndrome
Physical therapists and doctors may recommend orthotics for extra arch support, however it may take several weeks to months to adjust to orthotics and it is sometimes better not to add them during a training cycle. Some people feel immediately better with the shoe inserts, while it is too dramatic of a change for others. Discuss the options and best strategies with your healthcare provider.
Heat, ice, electric, cold laser, and ultrasound are common therapeutic modalities used to speed healing. Acupuncture and dry needling are additional treatment options for decreasing muscle spasms and trigger points throughout the glutes, hip, and thigh. Muscle spasm and tightness reduces range of motion and strength, which contributes to many chronic repetitive stress injuries. Combining traditional physical therapy techniques with an experienced massage therapist helps relieve muscle pain and spasms. Massage therapy helps relieve spasms that alter running gaits, especially in the hamstring, quadriceps, hip abductors, and adductors. Muscle tightness and loss of flexibility compounds the effects of weak hip and knee stabilizers, leading to more running injuries. Preventively working the leg muscles can keep you injury free.
Graston Technique, Active Release Technique (ART) and muscle therapy treatments help break up fascial adhesions that develop between muscles. Scar tissue develops with any overuse injury with years of overworking muscles and tendons. With microtearing and repetitive stress, the body attempts to increase fiber density in muscles and tendons. During this process, improper fibers can be placed between muscles which causes them to “stick together.” When enough of these fibers accumulate, it affects muscle movement and function. At a certain point, the accumulation of scar tissue begins altering normal muscle movements and contributes to developing IT band pain.
Graston Technique utilizes stainless steel instruments to slide along the skin, producing shear force to break up the scar tissue. Because of the design of the tools, it is very beneficial for any tendon or ligament injury around the knee. Graston Technique is a great treatment for both acute and chronic IT band tendino. Years of accumulated micro trauma with repetitive movements produce scar tissue that alters muscle movements, and Graston Technique is one of the best treatments for removing scar tissue and triggering the body’s proper repair.
In the office, immediate and short term goals are to decrease pain and inflammation. Soft tissues take weeks to remodel and rebuild. Treatment therapies accelerate healing while strengthening exercises help prevent future risks of injury. Long-term exercise goals combine multiple types of hip, knee, ankle, and foot exercises for strength, endurance, proprioception, and stability. Exercises are specifically given based on your areas of weakness. The weakest muscles are the ones that fatigue first. Strengthening the weakest muscle reduces risk of injuries the most, compared to just running more miles or strengthening the strongest muscles. Complex movement pattern exercises help re-train multiple muscle groups to work together for a more efficient running gait.
Why so Many Stability & Strengthening Exercises?
Distance runners are especially at risk for weakness in the lateral planes of movement, since they usually only train the muscles that propel them forward. Many runners do not maximize their use of gluteus maximus, which is the largest and strongest hip extensor. Runners are surprised at how much stronger and faster they feel when the utilize their gluteus maximus appropriately. In addition, many runners are weak on their lateral hip stabilizers, which leads to hip and knee wobble or an inefficient running gait. They waste energy with each step, and strengthening their stabilizers goes a long way to improve their speed and endurance.
Stability exercises train muscle groups to work together more efficiently by emphasizing joint position receptors input to the spinal cord and the body’s control of the muscle stabilizers in the hip, knee, ankle, and foot. The more unstable the surface, the harder the body has to work to maintain balance. The exercises usually start on the ground and move to more unstable surfaces with improvement. Foam, wobble boards, and BOSU balls are commonly used in therapy clinics and fitness centers. Vibration plates and machines make any exercise more difficult, as the body is continually knocked off balance which speeds the neurologic development. The body is a complicated machine; it is amazing how well it can compensate for months and years before developing an injury. For many runners, strengthening the hip will reduce hip, thigh, knee, and leg pain.
A lack of proprioception and foot strength is found in many knee and foot injuries, including plantar fasciitis, achilles tendinitis, shin splints, patella tendinitis, and chondromalacia patella. Runners often find their usual soft tissue injuries disappear when they strengthen their hip, knee, ankle, and foot stabilizers. Increasing efficiency and propioception reduces excessive forces applied to muscles, tendons, and joints. Runners waste less energy with inefficient movements and reduce the excessive pounding forces on their soft tissue, getting faster and having less running injuries. Improved neuromuscular control makes runners faster in every distance from a 5K to a marathon.
Preventing Iliotibial Band Syndrome
Prevention of IT band injury requires a combination of reducing stress to the IT band, using the proper footwear, and employing smart training, or at least smarter training than current levels. Rotate running surfaces and distances. Plan your rest days appropriately. Home ice treatment, stretching, specific stabilization exercises, massage, and foam rolling can help prevent future IT band injuries.
When suffering from Iliotibial Band Syndrome, it is important to take the appropriate steps quickly to reduce stress and strain on the tendon. Increasing strength and endurance of the hip, knee, ankle, and foot stabilizers reduces stress to the tissues by improving running efficiency. Running through the pain is not a great solution, as mild sprains often become severe IT band injuries which stop you from running your race. Work to quickly decrease pain and inflammation. Graston Technique helps remove scar tissue and soft tissue adhesions that contribute to altered gait mechanics. When you first start developing IT band symptoms, try the home care treatments and if the knee pain continues, seek treatment from an experienced provider to quickly return you to training. Mild iliotibial band sprains are much quicker and easier to resolve than moderate or severe sprains.