The Prognosis of Iliotibial Band Syndrome: Short vs. Long-term Recovery Morgan Toland, SPT June 28, 2016

Clinical Question Two patient scenarios with diagnosis of iliotibial band syndrome (ITBS) 1. 47 yo male cyclist/runner, better after 3 PT visits 2. 24 yo male runner, PT since end of April Why do some runners with ITBS recover after just several treatments, opposed to those who require weeks-months of physical therapy? What variables determine a shorter recovery in runners with ITBS? I came up with my clinical question after seeing 2 different patients both with ITBS who presented very differently One was an older recreational cylcist/runner who was better after just 3 sessions over the course of 2 weeks The other was a younger more avid runner who has been coming to PT for months

Background ITBS one of most common overuse injuries of lower extremity Leading cause of lateral knee pain in runners 1.6-12% of all running-related injuries Anatomy Originates in fibers of gluteus maximus, medius, and TFL to act as lateral stabilizer against hip adduction Inserts distally on Gerdy’s tubercle http://www.emedicinehealth.com/iliotibial_band_syndrome/article_em.htm

What Causes ITBS? Exact etiology unclear and is likely a combination of factors Proposed mechanisms: Sudden increase in mileage Continuous friction between ITB and lateral femoral condyle  irritation Maximal impingement after HS at ~30° knee flexion Gluteus medius weakness Premature firing and overuse of TFL and ITB Increased hip ADD and IR Increased rearfoot eversion Talar ADD causes tibial IR

Article 1 Nohren, B., Davis, I., & Hamill, J. (2007). Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomech, 22, 951-956. Prospective study

Purpose Compare lower extremity kinematic and kinetic variables of interest in female runners who develop ITBS vs. those who do not Hypothesis: those who develop ITBS will demonstrate greater peak hip ADD, knee IR, rearfoot eversion, and no difference in knee flexion at heel strike

Methods Subjects Data collection Female runners 18-45 years, 20+ miles per week 400 participants recruited over the course of 4 years Injury free at baseline Data collection Instrumented gait analysis during stance phase Retro-reflective markers on pelvis, thigh, shank, foot Run 25 m walkway at 3.7 m/s under force plate Followed monthly via email for two years Mileage Running-related injuries (diagnosed by medical professional)

Methods (contd. ) 18 participants developed ITBS Control group: 18 age and mileage-matched runners No previous hip or knee injury Instrumented gait analysis repeated Kinematic variables Peak hip ADD, knee IR, rearfoot eversion, knee flexion at HS Kinetic variables Peak hip ABD, knee ER, rearfoot inversion moments Injured leg of ITBS compared to right leg of control

Results Significant differences in ITBS: Increased hip ADD and knee IR during landing Remained more ADD and IR throughout stance Greater femoral ER Lower peak RF eversion Landed in slight inversion, but similar pattern to control throughout stance No significant differences between groups: Rearfoot inversion moments Hip ABD moment Knee flexion at HS Support of hypothesis Greater hip ADD and knee IR Rejection of hypothesis Less rearfoot eversion than control No significant differences in any of moments Landed in

Discussion Greater hip ADD  increased strain on ITB Inability to control hip with ABD due to weakness? However, no differences in ABD moments found Difference in timing vs. magnitude of activation? Niemuth et al. 2005: weak hip ABD of injured leg Is weakness cause or result of injury? Increased knee IR  moves insertion of ITB medial Increased compression against lateral condyle No bursa to protect ITB from sheering Knee IR comes from either femoral ER or tibial IR Greater femoral ER, less tibial IR Hip musculature imbalances? Co-contraction of internal and external rotators of hip required to keep femoral head in acetabulum during stance Glut min, anterior fibers of glut med, TFL all ABD and IR the femur Inadequate activation  increased femoral ER and ADD

Clinical Takeaway No data included regarding recovery Longer recovery? Faulty running mechanics Increased hip ADD and knee IR at HS

Article 2 Fredericson, M., Cookingham, C.L., Chaudhari, A.M., Dowdell, B. C., Oestreicher, N., & Sahrmann, S.A. (2000). Hip abductor weakness in distance runners with iliotibial band syndrome. Clinical Journal of Sport Medicine, 10(3), 169-175.

Purpose Compare injured limb hip abductor strength vs. healthy limb and control strength Does the correction of strength deficits (if present) lead to a successful return to running?

Methods Parameters Details Participants 24 collegiate & club long-distance runners Ages 18-41 (avg 27) Diagnosis of ITBS -Tenderness over lateral epicondyle -Reproducible pain with knee flexion/extension -No effusion, joint line tenderness, + McMurray’s Exclusion criteria History of knee injury, surgery, or symptoms of other knee pathology (PFPS, popliteus tendinitis, DJD) Control 30 cross-country & track runners at Stanford University No current spine or LE injury No history of non-treated LE injury within past 5 years Outcome measures Hip abductor strength via hand-held dynamometer (HHD) -Normalized for body weight and height -Baseline vs. post-PT after 6-week rehab

ITBS Rehabilitation Program 1x/week for 6 weeks treated by same PT NSAIDs prescribed until pain-free with ADL’s Ultrasound with corticosteroid gel first 1-2 visits Decrease inflammation 2 stretches for ITB holding 15 sec, performed 3x daily Gluteus medius strengthening focus Side-lying hip ABD and pelvic drops Initially 1 set of 15 reps  3 sets of 30 reps after several weeks

http://www. physioadvisor. com http://www.physioadvisor.com.au/exercises/flexibility-muscles-2/iliotibial-band-itb/ http://www.spineandsportspt.org/exercises/itb_stretch.php

Bottom leg flexed for balance, top leg in slight hip ext/ER Pelvic drop: standing on step on involved leg, lowering opposite pelvis Mirror used initially for visual feedback to ensure proper technique http://www.physicaltherapyfirst.com/knee-exercises/hip-abduction-sidelying/ http://lermagazine.com/cover_story/cleat-smarts-foot-posture-and-injury-risk-in-pitchers

Results: ABD Torque (%BWh) Males Females Pre-Rehab: Involved 6.86 ± 1.19 7.82 ± 1.93 Pre-Rehab: Non-involved 8.62 ± 1.16 9.82 ± 2.98 Control 9.73 ± 1.30 10.19 ± 1.19 Post-Rehab 10.38 = 51.4% increase 10.55 = 34.9% increase All comparisons statistically significant (p<0.05) Post-rehab: 22/24 runners pain-free, return to run program No reoccurrence at 6mo follow-up As you can see, the control group was stronger initially, but the ITBS had a drastic increase in strength after rehab And this was actually related to a successful return to run in 22/24 participants They also did not have any reoccurrence at the 6mo follow-up

Discussion Runners with ITBS demonstrate weaker hip ABD muscles in involved limb Why? Running primarily sagittal plane sport Less demand vs. sports requiring higher frontal/transverse plane movement Requirements of gluteus medius during running Eccentric contraction during HS to control hip ADD Concentric contraction during remainder of stance phase and propulsion into swing Gluteus medius weakness  decreased hip ABD control Leads to increased hip ADD/IR  increased ITB strain More vulnerable to impingement on lateral epicondyle during HS

Clinical Takeaway Decrease in symptoms and return to run is associated with strengthening of hip abductors Quicker recovery from ITBS? Present with decreased hip ABD strength Receive rehab program focused on hip strengthening From this study,, it is evident that a decrease in symptoms & return to run is associated with strengthening of hip abductors What I took from this study to relate back to my questions, is that those who develop ITBS due to hip musculature imbalances may recover quicker than others with different etiologies if receiving rehab program focused on hip strengthening

Article 3 Shamus, J., & Shamus, E. (2015). The management of iliotibial band syndrome with a multifaceted approach: a double case report. International journal of sports physical therapy, 10(3), 378.

Purpose Etiology of ITBS is unclear Friction between ITB and lateral epicondyle Decreased ITB and iliopsoas extensibility Abnormal LE kinematics Variety of evidence regarding most effective treatment Anti-inflammatory meds in initial stages Is inflammation the actual source or even present? Strengthening, neuromuscular re-education, manual therapy, stretching, shoes, training schedule Utilize the concept of regional interdependence as the basis of treatment of ITBS through a comprehensive model in 2 case reports

Case 1: Background 36 yo female diagnosed with left ITBS VAS: 9/10 stabbing pain at mile 2, forced to stop Self-care Static ITB stretching in standing & supine with strap Foam roll before/after each run x 20 minutes Previously running 2 marathons per year before children Goal: able to run half-marathon

Physical Examination Major findings Hypothesis Genu recurvatum and lordosis in standing Limited lumbar spine AROM L5 FRS, L on R sacral torsion, L innominate posteriorly rotated/outflare Posterior fibular head at superior tibiofibular joint Increased muscle tone Psoas, piriformis, lateral gastrocnemius Mild pronation bilaterally during gait analysis Hypothesis ITBS due to regional interdependence associated biomechanical & neuromuscular dysfunctions Multifaceted approach > local approach

Day 1 Interventions Exercises Response after treatment MET Grade III mobilization to superior tibiofibular joint ITB myofascial release Soft tissue mobilization to piriformis, lateral gastroc, psoas Exercises Upper/lower trunk rotation in side-lying Isometric hip ABD/ADD Postural re-education of knee position Dynamic stretching Verbal cues during gait retraining Response after treatment Ran 3 miles no pain (even ground, no cement) VAS 0/10 No ITB tenderness

Day 3 – Treatment 2 Interventions Exercises Response after treatment Soft tissue mobilization of psoas Exercises Side-lying hip ABD & clam shells Lateral step downs for knee neuromuscular re-education Instructed to run 3x per week, every other day Response after treatment No positional faults Normal muscle tone Running up to 5 miles without pain

Day 13 – Treatment 3 & Discharge Increase to one long run no more than 25% of weekly total mileage Progress long run every other week until able to run half-marathon

Discussion Multifaceted approach based upon impairments found during exam is most effective in decreasing recovery time Lumbosacral spine & LE joint mobilizations/techniques Vaughn: isolated knee pain abolished after lumbosacral mobilization Grassi et al: normalize weight distribution in LE after SI joint HVLA mobilization Soft tissue mobilization Immediate reduction in pain level Inflammation may not be driving source Strengthening Neuromuscular re-education Necessary for proper running form Running analysis/retraining Surface, shoes, training schedule

Putting It Together Limited evidence regarding factors that determine a longer or shorter recovery from ITBS Longer recovery possible factors: Faulty mechanics Increased hip ADD & knee IR during HS and stance Psychosocial factors Anxiety & stress about return to sport Perception of pain and disability No previous experience of injury or pain Shorter recovery possible factors: Etiology due to strength imbalance Multifaceted approach that identifies specific impairments

Questions???

References Fredericson, M., Cookingham, C.L., Chaudhari, A.M., Dowdell, B. C., Oestreicher, N., & Sahrmann, S.A. (2000). Hip abductor weakness in distance runners with iliotibial band syndrome. Clinical Journal of Sport Medicine, 10(3), 169-175. Grassi Dde O, de Souza M.Z., Ferrareto S.B., Montebelo, M.I., Guirro E.C. Immediate and lasting improvements in weight distribution seen in baropodometry following a high-velocity, low-amplitude thrust manipulation of the sacroiliac joint. Man Ther. 2011 Oct 16;16(5): 495-500. Niemuth, P. E., Johnson, R. J., Myers, M. J., & Thieman, T. J. (2005). Hip muscle weakness and overuse injuries in recreational runners. Clinical Journal of Sport Medicine, 15(1), 14-21. Nohren, B., Davis, I., & Hamill, J. (2007). Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomech, 22, 951-956. Shamus, J., & Shamus, E. (2015). The management of iliotibial band syndrome with a multifaceted approach: a double case report. International journal of sports physical therapy, 10(3), 378. Taunton, J., Ryan, B., Clement, B., McKenzie, C., Lloyd-Smith, R., Zumbo, D., 2002. A retrospective case-control analysis of 2002 running injuries. Br. J. Sports Med. 36. 95-101. Vaughn D.W. Isolated knee pain: a case report highlighting regional interdependence. J Orthop Sports Ther. 2008;38(1): 616-23.